Health trends in Canada 1990-2019: An analysis for the Global Burden of Disease Study.

OBJECTIVE: Monitoring trends in key population health indicators is important for informing health policies. The aim of this study was to examine population health trends in Canada over the past 30 years in relation to other countries. METHODS: We used data on disability-adjusted life years (DALYs), years of life lost (YLL), years lived with disability, life expectancy (LE), and child mortality for Canada and other countries between 1990 and 2019 provided by the Global Burden of Disease Study. RESULTS: Life expectancy, age-standardized YLL, and age-standardized DALYs all improved in Canada between 1990 and 2019, although the rate of improvement has leveled off since 2011. The top five causes of all-age DALYs in Canada in 2019 were neoplasms, cardiovascular diseases, musculoskeletal disorders, neurological disorders, and mental disorders. The greatest increases in all-age DALYs since 1990 were observed for substance use, diabetes and chronic kidney disease, and sense organ disorders. Age-standardized DALYs declined for most conditions, except for substance use, diabetes and chronic kidney disease, and musculoskeletal disorders, which increased by 94.6%, 14.6%, and 7.3% respectively since 1990. Canada's world ranking for age-standardized DALYs declined from 9th place in 1990 to 24th in 2019. CONCLUSION: Canadians are healthier today than in 1990, but progress has slowed in Canada in recent years in comparison with other high-income countries. The growing burden of substance abuse, diabetes/chronic kidney disease, and musculoskeletal diseases will require continued action to improve population health.

RéSUMé: OBJECTIF: La surveillance des tendances des indicateurs clés de la santé de la population est importante pour éclairer les politiques de santé. Dans cette étude, nous avons examiné les tendances de la santé de la population au Canada au cours des 30 dernières années par rapport à d'autres pays. MéTHODES: Nous avons utilisé des données sur les années de vie ajustées en fonction de l'incapacité (DALY), les années de vie perdues (YLL), les années vécues avec un handicap, l'espérance de vie (LE) et la mortalité infantile pour le Canada et d'autres pays entre 1990 et 2019, fournies par l'Étude mondiale sur le fardeau de la maladie. RéSULTATS: L'espérance de vie, les YLL ajustées selon l'âge et les DALY ajustées selon l'âge ont tous connu une amélioration au Canada entre 1990 et 2019, bien que le taux d'amélioration se soit stabilisé depuis 2011. Les cinq principales causes des DALY pour tous les âges au Canada en 2019 étaient les néoplasmes, les maladies cardiovasculaires, les affections musculosquelettiques, les affections neurologiques et les troubles mentaux. Les plus fortes augmentations des DALY pour tous les âges depuis 1990 ont été observées pour l'usage de substances, le diabète et les maladies rénales chroniques, ainsi que les troubles des organes sensoriels. Les DALY ajustées selon l'âge ont diminué pour la plupart des conditions, à l'exception de l'usage de substances, du diabète et des maladies rénales chroniques, ainsi que des troubles musculosquelettiques, qui ont augmenté de 94,6 %, 14,6 % et 7,3 % respectivement depuis 1990. Le classement mondial du Canada pour les DALY ajustées selon l'âge est diminué de la 9ième place en 1990 à la 24ième place en 2019. CONCLUSION: Les Canadiens sont en meilleure santé aujourd'hui qu'en 1990, mais les progrès se sont ralentis ces dernières années par rapport à d'autres pays à revenu élevé. La croissance du fardeau lié à l'abus de substances, au diabète/maladies rénales chroniques et aux affections musculosquelettiques exigera des actions continues pour améliorer la santé de la population.

Prediction of 2-year clinical outcome trajectories in patients undergoing anterior cervical discectomy and fusion for spondylotic radiculopathy.

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is often described as the gold standard surgical technique for cervical spondylotic radiculopathy. Although outcomes are considered favorable, there is little prognostic evidence to guide patient selection for ACDF. This study aimed to 1) describe the 24-month postoperative trajectories of arm pain, neck pain, and pain-related disability; and 2) identify perioperative prognostic factors that predict trajectories representing poor clinical outcomes. METHODS: In this retrospective cohort study, patients with cervical spondylotic radiculopathy who underwent ACDF at 1 of 12 orthopedic or neurological surgery centers were recruited. Potential outcome predictors included demographic, health, clinical, and surgery-related prognostic factors. Surgical outcomes were classified by trajectories of arm pain intensity, neck pain intensity (numeric pain rating scales), and pain-related disability (Neck Disability Index) from before surgery to 24 months postsurgery. Trajectories of postoperative pain and disability were estimated with latent class growth analysis, and prognostic factors associated with poor outcome trajectory were identified with robust Poisson models. RESULTS: The authors included data from 352 patients (mean age 50.9 [SD 9.5] years; 43.8% female). The models estimated that 15.5%-23.5% of patients followed a trajectory consistent with a poor clinical outcome. Lower physical and mental health-related quality of life, moderate to severe risk of depression, and longer surgical wait time and procedure time predicted poor postoperative trajectories for all outcomes. Receiving compensation and smoking additionally predicted a poor neck pain outcome. Regular exercise, physiotherapy, and spinal injections before surgery were associated with a lower risk of poor disability outcome. Patients who used daily opioids, those with worse general health, or those who reported predominant neck pain or a history of depression were at greater risk of poor disability outcome. CONCLUSIONS: Patients who undergo ACDF for cervical spondylotic radiculopathy experience heterogeneous postoperative trajectories of pain and disability, with 15.5%-23.5% of patients experiencing poor outcomes. Demographic, health, clinical, and surgery-related prognostic factors can predict ACDF outcomes. This information may further assist surgeons with patient selection and with setting realistic expectations. Future studies are needed to replicate and validate these findings prior to confident clinical implementation.

Postoperative recovery patterns following discectomy surgery in patients with lumbar radiculopathy.

This retrospective study of prospectively collected data aimed to identify unique pain and disability trajectories in patients following lumbar discectomy surgery. Patients of this study population presented chiefly with lumbar radiculopathy and underwent discectomy surgery from thirteen sites enrolled in the CSORN registry. Outcome variables of interest included numeric rating scales for leg/back pain and modified Oswestry disability index scores at baseline, 3, 12, and 24 months post-operatively. Latent class growth analysis was used to identify distinct courses in each outcome. Data from 524 patients revealed three unique trajectories for leg pain (excellent = 18.4%, good = 55.4%, poor = 26.3%), disability (excellent = 59.7%, fair = 35.6%, poor = 4.7%) and back pain (excellent = 13.0%, good = 56.4%, poor = 30.6%). Construct validity was supported by statistically significant differences in the proportions of patients attaining the criteria for minimal important change (MIC; 30%) or clinical success in disability (50% or Oswestry score ≤ 22) (p < 0.001). The variable proportions of patients belonging to poor outcome trajectories shows a disconnect between improved disability and persistence of pain. It will be beneficial to incorporate this information into the realm of patient expectation setting in concert with future findings of potential factors predictive of subgroup membership.

Effect of dry needling on lumbar muscle stiffness in patients with low back pain: A double blind, randomized controlled trial using shear wave elastography.

BACKGROUND: Dry needling treatment focuses on restoring normal muscle function in patients with musculoskeletal pain; however, little research has investigated this assertion. Shear wave elastography (SWE) allows quantification of individual muscle function by estimating both resting and contracted muscle stiffness. OBJECTIVE: To compare the effects of dry needling to sham dry needling on lumbar muscle stiffness in individuals with low back pain (LBP) using SWE. METHODS: Sixty participants with LBP were randomly allocated to receive one session of dry needling or sham dry needling treatment to the lumbar multifidus and erector spinae muscles on the most painful side and spinal level. Stiffness (shear modulus) of the lumbar multifidus and erector spinae muscles was assessed using SWE at rest and during submaximal contraction before treatment, immediately after treatment, and 1 week later. Treatment effects were estimated using linear mixed models. RESULTS: After 1 week, resting erector spinae muscle stiffness was lower in individuals who received dry needling than those that received sham dry needling. All other between-groups differences in muscle stiffness were similar, but non-significant. CONCLUSION: Dry needling appears to reduce resting erector spinae muscle following treatment of patients with LBP. Therefore, providers should consider the use of dry needling when patients exhibit aberrant stiffness of the lumbar muscles.

Effectiveness of Conservative Nonpharmacologic Therapies for Pain, Disability, Physical Capacity, and Physical Activity Behavior in Patients With Degenerative Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis.

OBJECTIVE: To investigate the effectiveness of conservative nonpharmacologic therapies on pain, disability, physical capacity, and physical activity outcomes in patients with degenerative lumbar spinal stenosis (LSS). DATA SOURCES: Systematic search of MEDLINE, EMBASE, CENTRAL, and PsycINFO from inception to November 4, 2019, without language restrictions. STUDY SELECTION: Pairs of review authors independently identified randomized controlled trials published in peer-reviewed scientific journals reporting on the effects of rehabilitation interventions on pain intensity (back or leg), disability, symptom severity, physical capacity, physical activity behavior, or adverse events (secondary outcome) in adults with LSS. The search identified 1718 records; data from 21 reports of 19 trials (1432 patients) were included. DATA EXTRACTION: Review author pairs independently extracted data and assessed included studies. We assessed risk of bias with the Cochrane tool, and overall study quality with the Grading of Recommendations Assessment, Development and Evaluation classification. DATA SYNTHESIS: We pooled data using random-effects meta-analyses; treatment effects were reported as mean differences (MD) and 95% confidence intervals (CI). Directed exercise and manual therapy was superior to self-directed or group exercise for improving short-term walking capacity (MD, 293.3 m; 95% CI, 61.7-524.9 m; low-quality evidence), back pain (MD, -1.1; 95% CI, -1.8 to -0.4; moderate quality evidence), leg pain (MD, -.9; 95% CI, -0.2 to -1.5; moderate-quality evidence), and symptom severity (MD, -0.3; 95% CI, -0.4 to -0.2; low quality evidence). There is very low quality evidence that rehabilitation is no better than surgery at improving intermediate- or long-term disability. Single trials provided conflicting evidence of effectiveness for a variety of therapies. CONCLUSIONS: For patients with LSS, there is low- to moderate-quality evidence that manual therapy with supervised exercises improves short-term walking capacity and results in small improvements in pain and symptom severity compared with self-directed or group exercise. The choice between rehabilitation and surgery for LSS is very uncertain owing to the very low quality of available evidence.

Preoperative Factors Predict Postoperative Trajectories of Pain and Disability Following Surgery for Degenerative Lumbar Spinal Stenosis.

STUDY DESIGN: Longitudinal analysis of prospectively collected data. OBJECTIVE: Investigate potential predictors of poor outcome following surgery for degenerative lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: LSS is the most common reason for an older person to undergo spinal surgery, yet little information is available to inform patient selection. METHODS: We recruited LSS surgical candidates from 13 orthopedic and neurological surgery centers. Potential outcome predictors included demographic, health, clinical, and surgery-related variables. Outcome measures were leg and back numeric pain rating scales and Oswestry disability index scores obtained before surgery and after 3, 12, and 24 postoperative months. We classified surgical outcomes based on trajectories of leg pain and a composite measure of overall outcome (leg pain, back pain, and disability). RESULTS: Data from 529 patients (mean [SD] age = 66.5 [9.1] yrs; 46% female) were included. In total, 36.1% and 27.6% of patients were classified as experiencing a poor leg pain outcome and overall outcome, respectively. For both outcomes, patients receiving compensation or with depression/depression risk were more likely, and patients participating in regular exercise were less likely to have poor outcomes. Lower health-related quality of life, previous spine surgery, and preoperative anticonvulsant medication use were associated with poor leg pain outcome. Patients with ASA scores more than two, greater preoperative disability, and longer pain duration or surgical waits were more likely to have a poor overall outcome. Patients who received preoperative chiropractic or physiotherapy treatment were less likely to report a poor overall outcome. Multivariable models demonstrated poor-to acceptable (leg pain) and excellent (overall outcome) discrimination. CONCLUSION: Approximately one in three patients with LSS experience a poor clinical outcome consistent with surgical non-response. Demographic, health, and clinical factors were more predictive of clinical outcome than surgery-related factors. These predictors may assist surgeons with patient selection and inform shared decision-making for patients with symptomatic LSS. LEVEL OF EVIDENCE: 2.

Patients undergoing surgery for lumbar spinal stenosis experience unique courses of pain and disability: A group-based trajectory analysis.

OBJECTIVE: Identify patient subgroups defined by trajectories of pain and disability following surgery for degenerative lumbar spinal stenosis, and investigate the construct validity of the subgroups by evaluating for meaningful differences in clinical outcomes. METHODS: We recruited patients with degenerative lumbar spinal stenosis from 13 surgical spine centers who were deemed to be surgical candidates. Study outcomes (leg and back pain numeric rating scales, modified Oswestry disability index) were measured before surgery, and after 3, 12, and 24 months. Group-based trajectory models were developed to identify trajectory subgroups for leg pain, back pain, and pain-related disability. We examined for differences in the proportion of patients achieving minimum clinically important change in pain and disability (30%) and clinical success (50% reduction in disability or Oswestry score ≤22) 12 months from surgery. RESULTS: Data from 548 patients (mean[SD] age = 66.7[9.1] years; 46% female) were included. The models estimated 3 unique trajectories for leg pain (excellent outcome = 14.4%, good outcome = 49.5%, poor outcome = 36.1%), back pain (excellent outcome = 13.1%, good outcome = 45.0%, poor outcome = 41.9%), and disability (excellent outcome = 30.8%, fair outcome = 40.1%, poor outcome = 29.1%). The construct validity of the trajectory subgroups was confirmed by between-trajectory group differences in the proportion of patients meeting thresholds for minimum clinically important change and clinical success after 12 postoperative months (p < .001). CONCLUSION: Subgroups of patients with degenerative lumbar spinal stenosis can be identified by their trajectories of pain and disability following surgery. Although most patients experienced important reductions in pain and disability, 29% to 42% of patients were classified as members of an outcome trajectory subgroup that experienced little to no benefit from surgery. These findings may inform appropriate expectation setting for patients and clinicians and highlight the need for better methods of treatment selection for patients with degenerative lumbar spinal stenosis.

Relationships between paraspinal muscle morphology and neurocompressive conditions of the lumbar spine: a systematic review with meta-analysis.

BACKGROUND: Individual study results have demonstrated unclear relationships between neurocompressive disorders and paraspinal muscle morphology. This systematic review aimed to synthesize current evidence regarding the relationship lumbar neurocompressive disorders may have with lumbar paraspinal muscle morphology. METHODS: Searches were conducted in seven databases from inception through October 2017. Observational studies with control or comparison groups comparing herniations, facet degeneration, or canal stenosis to changes in imaging or biopsy-identified lumbar paraspinal muscle morphology were included. Data extraction and risk of bias assessment were performed by review author pairs independent of one another. Morphological differences between individuals with and without neurocompressive disorders were compared qualitatively, and where possible, standardised mean differences were obtained. RESULTS: Twenty-eight studies were included. Lumbar multifidus fiber diameter was smaller on the side of and below herniation for type I [SMD: -0.40 (95% CI = -0.70, -0.09) and type II fibers [SMD: -0.38 (95% CI = -0.69, -0.06)] compared to the unaffected side. The distribution of type I fibers was greater on the herniation side [SMD: 0.43 (95% CI = 0.03, 0.82)]. Qualitatively, two studies assessing small angular fiber frequency and fiber type groupings demonstrated increases in these parameters below the herniation level. For diagnostic imaging meta-analyses, there were no consistent differences across the various assessment types for any paraspinal muscle groups when patients with herniation served as their own control. However, qualitative synthesis of between-group comparisons reported greater multifidus and erector spinae muscle atrophy or fat infiltration among patients with disc herniation and radiculopathy in four of six studies, and increased fatty infiltration in paraspinal muscles with higher grades of facet joint degeneration in four of five studies. Conflicting outcomes and variations in study methodology precluded a clear conclusion for canal stenosis. CONCLUSIONS: Based on mixed levels of risk of bias data, in patients with chronic radiculopathy, disc herniation and severe facet degeneration were associated with altered paraspinal muscle morphology at or below the pathology level. As the variability of study quality and heterogeneous approaches utilized to assess muscle morphology challenged comparison across studies, we provide recommendations to promote uniform measurement techniques for future studies. TRIAL REGISTRATION: PROSPERO 2015: CRD42015012985.

The Fear Avoidance Model predicts short-term pain and disability following lumbar disc surgery.

OBJECTIVE: To examine the prognostic value of the Fear Avoidance Model (FAM) variables when predicting pain intensity and disability 10-weeks postoperative following lumbar disc surgery. METHODS: We recruited patients scheduled for first-time, single level lumbar disc surgery. The following aspects of the FAM were assessed at preoperative baseline and after 10 postoperative weeks: numeric pain rating scale (0-10) for leg and back pain intensity separately, Pain Catastrophizing Scale (PCS), Fear Avoidance Beliefs Questionnaire (FABQ), Beck Depression Inventory (BDI), Oswestry Disability Questionnaire (ODI), and the International Physical Activity Questionnaire (IPAQ). Multivariate regression models were used to examine the best combination of baseline FAM variables to predict the 10-week leg pain, back pain, and disability. All multivariate models were adjusted for age and sex. RESULTS: 60 patients (30 females, mean [SD] age = 40.4 [9.5]) were enrolled. All FAM measures correlated with disability at baseline. Adding FAM variables to each of the stepwise multiple linear regression model explained a significant amount of the variance in disability (Adj. R2 = .38, p < .001), leg pain intensity (Adj. R2 = .25, p = .001), and back pain intensity Adj. R2 = .32, p < .001 at 10-weeks). After adjusting for age and gender, BDI and FABQ-work subscale were the only significant predictors added to each of the prediction models for the 10-week clinical outcome (leg pain, back pain, and ODI). CONCLUSION: BDI and FABQ-work subscale variables are associated with baseline pain intensity and disability and predict short-term pain and disability following lumbar disc surgery. Measuring these variables in patients being considered for lumbar disc surgery may improve patient outcome.

Exercise Improves V˙O2max and Body Composition in Androgen Deprivation Therapy-treated Prostate Cancer Patients.

INTRODUCTION: Prostate cancer is the most common cancer in men, and patients treated with androgen deprivation therapy (ADT) experience unfavorable changes in body composition and associated metabolic complications, which can increase the risk of cardiovascular disease. We examined the effect of a 6-month program of aerobic and resistance exercise aimed at improving body composition and cardiorespiratory health in this population. METHODS: Ninety-seven men (43-90 yr) with localized prostate cancer receiving ADT were randomized to either exercise (EX, n = 50) or usual care (CON, n = 47). Supervised exercise was undertaken twice weekly at moderate to high intensity. Measures of cardiorespiratory capacity (V˙O2max), resting metabolic rate, central blood pressure, hemodynamic variables, blood markers, and body composition were assessed. RESULTS: There was a significant group-time interaction present for V˙O2max (P = 0.033) with a treatment effect for EX of 0.11 L·min (95% confidence interval [CI] = 0.04-0.19) (relative to body mass = 1.3 mL·kg·min, 95% CI = 0.3-2.3) and fat oxidation (P = 0.037) of 12.0 mg·min (95% CI = 2.3-21.7). Similarly, there was a significant improvement in glucose (P < 0.001) for EX of -0.5 mmol·L (95% CI = -0.8 to -0.3), with no change in prostate-specific antigen or testosterone as a result of exercise. Body composition was enhanced for EX with adjusted mean differences in lean mass (P = 0.015) of 0.8 kg (95% CI = 0.3-1.3), total fat mass (P = 0.020) of -1.1 kg (95% CI = -1.8 to -0.5), and trunk fat mass (P < 0.001) of -1.0 kg (95% CI = -1.4 to -0.6). CONCLUSION: A 6-month combined aerobic and resistance exercise program has a significant favorable effect on cardiorespiratory capacity, resting fat oxidation, glucose, and body composition despite the adverse effects of hormone suppression. Combined aerobic and resistance training should be considered a key adjuvant component in men undergoing ADT for the treatment of prostate cancer.

Predictors of clinical outcome following lumbar disc surgery: the value of historical, physical examination, and muscle function variables.

PURPOSE: Explore the relationships between preoperative findings and clinical outcome following lumbar disc surgery, and investigate the prognostic value of physical examination findings after accounting for information acquired from the clinical history. METHODS: We recruited 55 adult patients scheduled for first time, single-level lumbar discectomy. Participants underwent a standardized preoperative evaluation including real-time ultrasound imaging assessment of lumbar multifidus function, and an 8-week postoperative rehabilitation programme. Clinical outcome was defined by change in disability, and leg and low back pain (LBP) intensity at 10 weeks. Linear regression models were used to identify univariate and multivariate predictors of outcome. RESULTS: Univariate predictors of better outcome varied depending on the outcome measure. Clinical history predictors included a greater proportion of leg pain to LBP, pain medication use, greater time to surgery, and no history of previous physical or injection therapy. Physical examination predictors were a positive straight or cross straight leg raise test, diminished lower extremity strength, sensation or reflexes, and the presence of postural abnormality or pain peripheralization. Preoperative pain peripheralization remained a significant predictor of improved disability (p = 0.04) and LBP (p = 0.02) after accounting for information from the clinical history. Preoperative lumbar multifidus function was not associated with clinical outcome. CONCLUSIONS: Information gleaned from the clinical history and physical examination helps to identify patients more likely to succeed with lumbar disc surgery. While this study helps to inform clinical practice, additional research confirming these results is required prior to confident clinical implementation.

The evaluation of lumbar multifidus muscle function via palpation: reliability and validity of a new clinical test.

BACKGROUND CONTEXT: The lumbar multifidus muscle provides an important contribution to lumbar spine stability, and the restoration of lumbar multifidus function is a frequent goal of rehabilitation. Currently, there are no reliable and valid physical examination procedures available to assess lumbar multifidus function among patients with low back pain. PURPOSE: To examine the inter-rater reliability and concurrent validity of the multifidus lift test (MLT) to identify lumbar multifidus dysfunction among patients with low back pain. STUDY DESIGN/SETTING: A cross-sectional analysis of reliability and concurrent validity performed in a university outpatient research facility. PATIENT SAMPLE: Thirty-two persons aged 18 to 60 years with current low back pain and a minimum modified Oswestry disability score of 20%. Study participants were excluded if they reported a history of lumbar spine surgery, lumbar radiculopathy, medical red flags, osteoporosis, or had recently been treated with spinal manipulation or trunk stabilization exercises. OUTCOME MEASURES: Concurrent measures of lumbar multifidus muscle function at the L4-L5 and L5-S1 levels were obtained with the MLT (index test) and real-time ultrasound imaging (reference standard). METHODS: The inter-rater reliability of the MLT was examined by measuring the level of agreement between two blinded examiners. Concurrent validity of the MLT was investigated by comparing clinicians' judgments with real-time ultrasound imaging measures of lumbar multifidus function. RESULTS: Inter-rater reliability of the MLT was substantial to excellent (κ=0.75 to 0.81, p≤.01) and free from errors of bias and prevalence. When performed at L4-L5 or L5-S1, the MLT demonstrated evidence of concurrent validity through its relationship with the reference standard results at L4-L5 (rbis=0.59-0.73, p≤.01). The MLT generally failed to demonstrate a relationship with the reference standard results from the L5-S1 level. CONCLUSIONS: Our results provide preliminary evidence supporting the reliability and validity of the MLT to assess lumbar multifidus function at the L4-L5 spinal level. Additional research examining the measurement properties and utility of this test should be undertaken before confident implementation with patients.

Serious Adverse Events and Spinal Manipulative Therapy of the Low Back Region: A Systematic Review of Cases.

OBJECTIVE: The purpose of this study was to systematically search the literature for studies reporting serious adverse events following lumbopelvic spinal manipulative therapy (SMT) and to describe the case details. METHODS: A systematic search was conducted in PubMed including MEDLINE, EMBASE, CINAHL, and The Cochrane Library up to January 12, 2012, by an experienced reference librarian. Study selection was performed by 2 independent reviewers using predefined criteria. We included cases involving individuals 18 years or older who experienced a serious adverse event following SMT applied to the lumbar spine or pelvis by any type of provider (eg, chiropractic, medical, physical therapy, osteopathic, layperson). A serious adverse event was defined as an untoward occurrence that results in death or is life threatening, requires hospital admission, or results in significant or permanent disability. We included studies published in English, German, Dutch, and Swedish. RESULTS: A total of 2046 studies were screened, and 41 studies reporting on 77 cases were included. Important case details were frequently unreported, such as descriptions of SMT technique, the pre-SMT presentation of the patient, the specific details of the adverse event, time from SMT to the adverse event, factors contributing to the adverse event, and clinical outcome. Adverse events consisted of cauda equina syndrome (29 cases, 38% of total); lumbar disk herniation (23 cases, 30%); fracture (7 cases, 9%); hematoma or hemorrhagic cyst (6 cases, 8%); or other serious adverse events (12 cases, 16%) such as neurologic or vascular compromise, soft tissue trauma, muscle abscess formation, disrupted fracture healing, and esophageal rupture. CONCLUSIONS: This systematic review describes case details from published articles that describe serious adverse events that have been reported to occur following SMT of the lumbopelvic region. The anecdotal nature of these cases does not allow for causal inferences between SMT and the events identified in this review. Recommendations regarding future case reporting and research aimed at furthering the understanding of the safety profile of SMT are discussed.

Early multimodal rehabilitation following lumbar disc surgery: a randomised clinical trial comparing the effects of two exercise programmes on clinical outcome and lumbar multifidus muscle function.

BACKGROUND: The optimal components of postoperative exercise programmes following single-level lumbar discectomy have not been identified. Facilitating lumbar multifidus (LM) function after discectomy may improve postoperative recovery. The aim of this study was to compare the clinical and muscle function outcomes of patients randomised to receive early multimodal rehabilitation following lumbar discectomy consisting of exercises targeting specific trunk muscles including the LM or general trunk exercises. METHODS: We included participants aged 18 to 60 years who were scheduled to undergo single-level lumbar discectomy. After two postoperative weeks, participants were randomly assigned to receive an 8-week multimodal exercise programme including either general or specific trunk exercises. The primary outcome was pain-related disability (Oswestry Index). Secondary outcomes included low back and leg pain intensity (0-10 numeric pain rating scale), global change, sciatica frequency, sciatica bothersomeness and LM function measured with real-time ultrasound imaging. Treatment effects 10 weeks and 6 months after surgery were estimated with linear mixed models. RESULTS: 61 participants were randomised to receive a general trunk (n=32) or specific (n=29) exercise programme. There were no between-group differences in clinical or muscle function outcomes. Participants in both groups experienced improvements in most outcome measures. CONCLUSIONS: Following lumbar discectomy, multimodal rehabilitation programmes comprising specific or general trunk exercises have similar effects on clinical and muscle function outcomes. Local factors such as the individual patient characteristics identified by specific assessment findings, clinician expertise and patient preferences should direct therapy selection when considering the types of exercises tested in this trial for inclusion in rehabilitation programmes following lumbar disc surgery.

Criterion validity of manual assessment of spinal stiffness.

Assessment of spinal stiffness is widely used by manual therapy practitioners as a part of clinical diagnosis and treatment selection. Although studies have commonly found poor reliability of such procedures, conflicting evidence suggests that assessment of spinal stiffness may help predict response to specific treatments. The current study evaluated the criterion validity of manual assessments of spinal stiffness by comparing them to indentation measurements in patients with low back pain (LBP). As part of a standard examination, an experienced clinician assessed passive accessory spinal stiffness of the L3 vertebrae using posterior to anterior (PA) force on the spinous process of L3 in 50 subjects (54% female, mean (SD) age = 33.0 (12.8) years, BMI = 27.0 (6.0) kg/m(2)) with LBP. A criterion measure of spinal stiffness was performed using mechanized indentation by a blinded second examiner. Results indicated that manual assessments were uncorrelated to criterion measures of stiffness (spearman rho = 0.06, p = 0.67). Similarly, sensitivity and specificity estimates of judgments of hypomobility were low (0.20-0.45) and likelihood ratios were generally not statistically significant. Sensitivity and specificity of judgments of hypermobility were not calculated due to limited prevalence. Additional analysis found that BMI explained 32% of the variance in the criterion measure of stiffness, yet failed to improve the relationship between assessments. Additional studies should investigate whether manual assessment of stiffness relates to other clinical and biomechanical constructs, such as symptom reproduction, angular rotation, quality of motion, or end feel.

Postoperative rehabilitation following lumbar discectomy with quantification of trunk muscle morphology and function: a case report and review of the literature.

STUDY DESIGN: A case report and literature review. BACKGROUND: Optimizing clinical outcomes following lumbar disc surgery is a research priority; however, relatively little attention has been paid to the postoperative management of this population. The transversus abdominis and lumbar multifidus (LM) muscles appear to play a unique role in lumbar spine stability, and may relate to clinical outcome following lumbar disc surgery. The purpose of this case report was to describe the preoperative LM morphology, clinical outcome, and change in transversus abdominis and LM muscle activation in a patient following lumbar disc surgery and motor control exercise initiated in the early postoperative period. CASE DESCRIPTION: A 29-year-old female underwent an 8-week postoperative rehabilitation program emphasizing motor control exercises to restore trunk muscle function 10 days following lumbar disc surgery. OUTCOMES: The patient experienced clinically important improvements in pain and disability following the postoperative rehabilitation program. Substantial improvements in muscle activation were observed of the transversus abdominis and the LM at the L4-5 level. Minimal change in LM activation and a higher proportion of intramuscular fat was observed at the L5-S1 level. DISCUSSION: This case report represents limited evidence regarding the feasibility of instituting a rehabilitation program in the early postoperative period following lumbar disc surgery. Improvements in clinical status and muscle function were observed, and a differential change in muscle activation between the L4-5 and L5-S1 levels was noted. The literature regarding rehabilitation following lumbar disc surgery, as well as the neuromuscular changes observed in this population, was reviewed. Additionally, a novel method of examining LM morphology was described and suggestions were made for directions of future research. LEVEL OF EVIDENCE: Therapy, level 4.

Cryoablation in the musculoskeletal system.

Pain palliation can be challenging in patients with metastases to the musculoskeletal system, and conventional therapy can be less than optimal for pain management. Recent advances in technology have allowed for the addition of image-guided ablation to the armamentarium for treating musculoskeletal metastases. This article focuses on one such technique, percutaneous cryoablation, and the experiences with this technique at the authors' institution. After a brief review of the history and theory behind cryoablation, the basic technique of percutaneous cryoablation of musculoskeletal metastases is described. This is followed by a review of the cases that have been performed at the authors' institution. A discussion on the many advantages and relatively few disadvantages of this exciting new technique is then put forth. Percutaneous cryoablation is beginning to emerge as a useful method of image-guided ablation of musculoskeletal metastases. As data continue to mount on this exciting application of new technology, image-guided cryoablation of musculoskeletal metastases appears to hold much promise in the treatment of pain related to these lesions.