Reference values of lumbar spine range of motion by sex and age based on the assessment of supine trunk lateral bending-A preliminary study.

[Purpose] The purpose of this study was to clarify the preliminary reference values for the lumbar spine range of motion associated with lateral bending exercises by gender and age group. [Methods] Subjects were 82 volunteers without low back pain, including five males and five females in each age group from 16-19 to 80-89 years. All subjects underwent radiographs of the lumbar spine with lateral flexion; the range of lateral flexion of the vertebrae from T12 to the sacrum (ROLB) was measured twice by three observers. [Results] The ROLB of the entire T12-S1 of all subjects showed a significant negative correlation with age in both sexes (p < 0.01). The ROLB of the lumbar spine tended to be greater in females, with a statistically significant difference between those aged 16-19 and 70-79 (p < 0.05). Lateral flexion angles for each intervertebral segment were largest at L3-L4 and smallest at L5-S1 (0.7°). [Conclusion] Lumbar ROLB reference values were examined by gender and age group; ROLB was greatest in L3-L4, and ROLB tended to be lower in older age groups.

Assessment of Lumbar Spinal Stenosis as a Risk Factor for Development of Sleep Disorder: The Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS).

Purpose: Insomnia has been reported to coexist with various musculoskeletal disorders. Although lumbar spinal stenosis (LSS) is the most frequently operated on spinal disease, the causal relationship between LSS and development of sleep disorders remains unclear due to lack of longitudinal studies. This study aimed to determine whether LSS was a risk factor for developing new sleep disorders, primarily insomnia, using a prospective cohort of community residents. Patients and Methods: This study was a prospective cohort study. Participants aged ≥65 years from the "Locomotive Syndrome and Health Outcomes in Aizu Cohort Study (LOHAS)" conducted in 2008 formed our study population. LSS was diagnosed using the self-administered, self-reported history questionnaire, a validated diagnostic support tool for LSS. Sleep disorder was investigated using a questionnaire during the 2-year follow-up. The impact of LSS on sleep disorder onset was analyzed after adjusting for potential confounders, such as age, sex, obesity, hypertension, diabetes, depression, and smoking habits, using propensity score matching. Results: Of the 489 participants who were followed up for two years, 38 (7.8%) had newly developed a sleep disorder in 2010. After adjusting for confounding factors, a comparison of 133 participants each in the control and LSS groups showed significantly higher frequency of new-onset sleep disorders (19 [14.3%] in the LSS group versus 6 [4.5%] in the control group). Conclusion: LSS was found to be an independent risk factor for sleep disorders.

Association between single limb standing test results and healthcare costs among community-dwelling older adults.

BACKGROUND AND OBJECTIVE: Identifying risks for older adults who will require healthcare resources is critical for the government, healthcare providers, and consumers. The objective of this study was to examine the relationship between the results of the single limb standing (SLS) test and healthcare costs among community-dwelling older adults. METHODS: We used data obtained from a population-based prospective cohort study of the residents of Tadami town in Fukushima Prefecture, Japan. The participants were above 60 years of age and had undergone annual health check-ups, and data on their healthcare costs over the two-year study period were available. A censored regression model adjusted for potential confounders was used to estimate the mean difference in total healthcare costs between participants who could remain standing on a single limb for at least 30 s and those who could not. RESULTS: Healthcare costs of participants who passed the SLS test were significantly lower than those who did not. The mean difference between the two groups' healthcare costs was 4064 USD (95 % confidence interval: 2661-5467 USD, p < 0.05). After adjusting for potential confounders, the mean difference between the two groups was smaller (1686 USD) but remained statistically significant (95 % confidence interval: 125-3246 USD, p < 0.05). CONCLUSIONS: Among community-dwelling older adults, limited static balance (SLS time <30 s) was found to be associated with high healthcare costs in the two years after the SLS test. The SLS test may help identify individuals at high risk of becoming frequent users of healthcare services in the future.

Age-Specific Prevalence and Clinical Characteristics of Humeral Medial Epicondyle Apophysitis and Osteochondritis Dissecans: Ultrasonographic Assessment of 4249 Players.

BACKGROUND: Traction apophysitis of medial epicondyle (MEC) lesions and osteochondritis dissecans (OCD) of the capitellum are common elbow injuries in adolescent baseball players. However, the age-specific prevalence of these pathologies and their influence on elbow pain remain unknown. PURPOSE: To investigate the age-specific prevalence of each MEC lesion and capitellar OCD and to identify the incidence of elbow pain in each condition. STUDY DESIGN: Descriptive epidemiology study. METHODS: Study participants consisted of 4249 baseball players aged 6 to 17 years. A questionnaire was used to assess history of elbow pain, and morphological changes of the elbow joint were assessed using ultrasonography. RESULTS: Regarding MEC lesions, fragmented (FG) and irregular (IR) lesions both reached their greatest respective prevalence at 11 to 12 years of age. After 14 years of age, IR decreased sharply, whereas FG was maintained at approximately 10%. Hypertrophic (HT) lesions increased sharply, reaching over 50% at 16 years of age, while there was a decrease in IR and FG lesions in the same age group. The prevalence of capitellar OCD remained the same (approximately 2%) throughout all ages except for in players aged 7 to 8 years (>7%). Players with MEC lesions had significantly greater prevalence of a history of elbow pain compared with those without (68.0% vs 39.1%) and were at a significantly greater risk for FG lesions (odds ratio [OR], 4.04; 95% CI, 3.16-5.22) compared with IR (OR, 3.22; 95% CI, 2.44-4.27) and HT lesions (OR, 2.03; 95% CI, 1.75-2.36). Players with capitellar OCD also had a significantly greater risk of a history of elbow pain (OR, 2.34; 95% CI, 1.40-4.11). CONCLUSION: Controlling the amount of practice and its intensity according to the condition of each player in the preadolescent and adolescent periods may be important in accelerating bony healing and decreasing preventable elbow pain in adulthood.

Ultrasonographic assessment of the flexor pronator muscles as a dynamic stabilizer of the elbow against valgus force.

Flexor pronator muscles (FPMs) play a key role in stabilizing the elbow joint against valgus forces. However, no studies have investigated the in vivo kinematics of FPMs against these forces on the elbow. This study aimed to clarify the in vivo contribution of each FPM as a dynamic stabilizer in a clinical situation.Twelve healthy volunteers participated in this study. Verbal informed consent was obtained from all subjects. The elbow was flexed to 90 degrees, and the forearm was placed in the neutral position. Manual valgus stress was applied to the elbow joint until maximal shoulder external rotation was achieved. The width of the ulnohumeral joint space and the ulnar shift of the sublime tubercle were measured before and after isometric contraction of FPMs using ultrasonography.The horizontal distances were decreased 1.1±0.6 mm after forearm pronation, 0.6±0.5 mm after wrist palmar flexion, 0.1±0.4 mm after wrist ulnar flexion, and 0.2±0.5 mm after finger flexion. Significant changes were observed during forearm pronation, wrist palmar flexion, and finger flexion but not during wrist ulnar flexion (p<0.05). The sublime tubercle was significantly shifted 0.5±0.1 mm medially after forearm pronation, 0.2±0.1 mm medially after wrist palmar flexion, and 0.1±0.1 mm laterally after wrist ulnar flexion and finger flexion (p<0.05). The FPMs, especially the pronator teres and the flexor carpi radialis, function as dynamic stabilizers against elbow valgus stress. The results of this study may be useful in developing injury prevention and rehabilitation strategies for throwing injuries of the elbow.

An outcome measure for patients with cervical myelopathy: the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ): an average score of healthy volunteers.

BACKGROUND: An outcome measure to evaluate the neurological function of patients with cervical myelopathy was proposed by the Japanese Orthopaedic Association (JOA score) and has been widely used in Japan. However, the JOA score does not include patients' satisfaction, disability, handicaps, or general health, which can be affected by cervical myelopathy. In 2007, a new outcome measure, the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ), which is a self-administered questionnaire, was developed. However, the influence of age and gender on the scores has not been fully examined. The purpose of this study was to establish the standard value of the JOACMEQ by age using healthy volunteers. METHODS: This study was conducted in 23 university hospitals and their affiliated hospitals from September to December 2011. The questionnaire included 24 questions for evaluation of physical function of the cervical spine and spinal cord. A total of 1,629 healthy volunteers were recruited for the study. The ages ranged from 20 to 89 years old. RESULTS: The volunteers comprised 798 men and 831 women. In the elderly healthy volunteers, the JOACMEQ scores decreased with age. In general, the scores for cervical spine function and upper/lower extremity function were retained up to the 60s, then decreased in the 70s and 80s. The scores for quality of life were retained up to the 70s; however, the score for bladder function was retained up to the 40s, then declined with age from the 50s to 80s. CONCLUSION: The standard values of the JOACMEQ by age were established. Differences in the scores were found among different generations. Patients with cervical myelopathy should be evaluated with this new self-administered questionnaire taking into account the standard values according to different ages.

Assessment of pain due to lumbar spine diseases using MR spectroscopy: a preliminary report.

BACKGROUND DATA: There is a considerable difference in pain perception among individuals. In patients with chronic pain, recent studies using fMRI, PET and SPECT have shown that functional changes mainly occurred in the anterior cingulate cortex (ACC), prefrontal cortex (PFC) and thalamus. Brain magnetic resonance spectroscopy (MRS) can evaluate brain chemistry by measuring metabolites such as N-acetyl aspartate (NAA). The purpose of this study was to analyze whether brain MRS could assess pain due to lumbar spine diseases. METHODS: NAA levels were determined relative to the concentration of creatine/phosphocreatine complex (Cr) and choline (Cho), which is commonly used as an internal standard. The NAA/Cr and NAA/Cho ratios in the ACC, PFC and thalamus were compared between six patients with unilateral pain (left side) and six control patients without pain. RESULTS: In the right thalamus (contralateral side to symptom), the NAA/Cr in the patients with pain was statistically significantly lower compared with the control patients (p < 0.05). Also, in the right thalamus, the NAA/Cho in pain patients was significantly lower compared with controls (p < 0.01). When considering just the right thalamus, there were statistically significant correlations between the numerical rating scale for pain (NRS) and NAA values. CONCLUSIONS: Lumbar pain can be assessed indirectly by analyzing the decrease in NAA concentration in the thalamus.

Locomotor dysfunction and risk of cardiovascular disease, quality of life, and medical costs: design of the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS) and baseline characteristics of the study population.

BACKGROUND: There is little evidence regarding long-term outcomes of locomotor dysfunction such as cardiovascular events, quality of life, and death. We are conducting a prospective cohort study to evaluate risk of cardiovascular disease, quality of life, medical costs, and mortality attributable to locomotor dysfunction. The present study determined baseline characteristics of participants in the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS). METHODS: Cohort participants were recruited from residents between 40 and 80 years old who received regular health check-ups conducted by local government each year between 2008 and 2010 in Minami-Aizu Town and Tadami Town in Fukushima Prefecture, Japan. Musculoskeletal examination included assessment of physical examination of the cervical and lumbar spine, and upper and lower extremities and of physical function, such as grasping power, one-leg standing time, and time for the 3-m timed up-and-go test. Cardiovascular risk factors, including blood pressure and biological parameters, were measured at annual health check-ups. We also conducted a self-administered questionnaire survey. RESULTS: LOHAS participants comprised 1,289 men (mean age 65.7 years) and 1,954 women (mean age 66.2 years) at the first year. The proportion of obese individuals (body mass index 25.0 kg/m(2)) was 31.9% in men and 34.3% in women, and 41.0% of participants reported being followed up for hypertension, 7.0% for diabetes, and 43.6% for hypercholesterolemia. Prevalence of lumbar spinal stenosis was 10.7% in men and 12.9% in women, while prevalence of low back pain was 15.8% in men and 17.6% in women. CONCLUSION: The LOHAS is a novel population-based prospective cohort study that will provide an opportunity to estimate the risk of cardiovascular disease, quality of life, medical costs, and mortality attributable to locomotor dysfunction, and to provide the epidemiological information required to develop policies for detection of locomotor dysfunction.

Development and validation of a quality of life scale specific for lumbar spinal stenosis.

STUDY DESIGN: A cross-sectional study. OBJECTIVE: To develop a reliable and valid instrument to measure quality of life (QOL) specifically targeting patients with lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: Studies on LSS have investigated the effectiveness of various types of treatments using health-related QOL. However, patients with LSS have various symptoms, and these symptoms change with posture, typical activities of daily living, etc. Thus, an LSS-specific scale to measure QOL is needed. METHODS: We postulated 7 subdomains for LSS-specific QOL and accordingly, item pool was developed, focus group interviews of patients with LSS and qualitative analysis were conducted, resulting in preliminary version of QOL scale. Then, 189 patients with a diagnosis of LSS completed this preliminary version. Exploratory factor analysis was conducted to examine the factorial validity. Cronbach alpha coefficient and the test-retest method were used to assess the reliability. The criterion-based validity was determined using walking capacity, recommended treatment level judged by orthopedists, and LSS symptom scale scores. RESULTS: Qualitative study confirmed the 7 domains but showed needs of addition and deletion of some items, resulting in 31 items. With factor analysis, after exclusion of 3 items, the remaining 28 items demonstrated strong unidimensionality. Cronbach alpha was 0.96. The coefficient of test-retest reliability was 0.86. Walking capacity, recommended treatment level, and LSS symptom scale scores were significantly correlated with the QOL scale scores. CONCLUSION: A 28-item QOL scale specifically targeting patients with LSS was developed, and its reliability and validity were confirmed.

Surgical treatment assessment using the Japanese orthopedic association cervical myelopathy evaluation questionnaire in patients with cervical myelopathy: a new outcome measure for cervical myelopathy.

STUDY DESIGN: Prospective study of assessment of surgical results using a new outcome measure for cervical myelopathy, the Japanese Orthopedic Association cervical myelopathy evaluation questionnaire (JOACMEQ). OBJECTIVE: To clarify correlations between pre- and postoperative JOACMEQ severity scores for cervical spine operations and grip strength and grip-and-release test, as objective evaluations, as well as correlations with the 8 subscales of the short form-36 (SF-36). METHODS: For pre- and postoperative evaluations, we examined 87 subjects who had undergone cervical spine operations and could be followed up for > or =6 months. JOACMEQ and the Japanese version of SF-36 were administered along with grip strength and grip-and-release tests, immediately preoperatively and 6 months postoperatively. Based on JOACMEQ severity scores pre- and postoperatively, treatment effectiveness was determined for cervical spine function, upper extremity function, lower extremity function, bladder function, and quality of life (QOL). We also clarified correlations between JOACMEQ scores and upper extremity function using grip strength and the grip-and-release test. In addition, correlations between the 5 JOACMEQ severity scores and the 8 subscales of SF-36 were analyzed. RESULTS: Effective rate of treatment was lower for upper extremity function than for other items (i.e., lower extremity function, bladder function, and QOL), and upper extremity function showed a different tendency for subjective improvement of symptoms following surgery compared to other items. JOACMEQ scores for upper extremity function, as subjective evaluations, may not necessarily improve even though improvements are seen in objective indicators such as grip strength and grip-and-release tests. CONCLUSION: JOACMEQ offers an effective method of evaluation from the perspective of patient evaluations of QOL.

Higher internality of health locus of control is associated with the use of complementary and alternative medicine providers among patients seeking care for acute low-back pain.

OBJECTIVES: Given that persons with a stronger belief in internal health locus of control (HLC) have been shown to comply well with medical advice, HLC internality may play an important role in low-back pain (LBP) prevention and management because it requires the patient's own commitment. Previous studies in conditions other than LBP have shown that the use of complementary and alternative medicine (CAM) is associated with high HLC internality. Here, we examined the relationship between CAM facility visits and internality of HLC in persons with LBP. METHODS: We analyzed the data from the Health Diary Study, which surveyed the health-related behavior of 3477 persons sampled from the general population of Japan. Among 2377 participants aged 18 to 75 years, 673 reported LBP during the study period. We examined CAM facility visits and HLC among 81 previously untreated LBP patients who sought care from western medical doctors or CAM providers during the 1-month study period. RESULTS: Of the 81 patients, 40 reported at least 1 CAM visit, whereas 41 visited western medical doctors only. Participants who visited CAM facilities had a higher internality score than those who visited western medical doctors after controlling for age, sex, size of residential city, and bodily pain score of the Short Form-8 Health Survey scale. DISCUSSION: Visitors to CAM facilities had a stronger belief in internal HLC. This finding suggests that visitors to CAM facilities are more sensitive to educational intervention for the self-management of LBP than those who visit western medicine. In order not to miss the opportunity of reaching these patients, the education should be more emphasized on CAM facilities.

Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Part 2. Verification of its reliability : The Subcommittee on Low Back Pain and Cervical Myelopathy Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association.

BACKGROUND: The project to develop a new Japanese Orthopaedic Association (JOA) score rating system for low back disorders, the JOA Back Pain Evaluation Questionnaire (JOABPEQ), is currently in progress. Part 1 of the study selected 25 "candidate" items for use on the JOABPEQ. The purpose of this current Part 2 of the study was to verify the reliability of the questionnaire. METHODS: A total of 161 patients with low-back disorders of any type participated in the study. Each patient was interviewed twice at an interval of 2 weeks using the same questionnaire. The reliability of the questionnaire was evaluated by determining the extension of the kappa and weighted kappa coefficients. RESULTS: Both kappa and weighted kappa were more than 0.50 for all but one item, which was 0.48. The lower 95% confidence interval exceeded 0.4 in all but two items, which was 0.39. This implied that the test-retest reliability of JOABPEQ was acceptable as a measure of outcome. CONCLUSIONS: The tentative questionnaire of the JOABPEQ with 25 items was confirmed to be reliable enough to describe the quality of life of patients who suffer low back disorders.

Spinal stenosis: assessment of motor function, VEGF expression and angiogenesis in an experimental model in the rat.

Reduction of blood flow in compressed nerve roots is considered as one important mechanism of induction of neurogenic intermittent claudication in lumbar spinal canal stenosis. Vascular endothelial growth factor (VEGF) is a potent stimulator of angiogenesis, and is increased in expression in hypoxic conditions. The objective of this study was to examine if cauda equina compression affects motor function and induces expression of VEGF and angiogenesis. The cauda equina was compressed by placing a piece of silicone rubber into the L5 epidural space. Walking duration was examined by rota-rod testing. The compressed parts of the cauda equina and L5 dorsal root ganglion (DRG) were removed at 3, 7, 14, or 28 days after surgery, and processed for immunohistochemistry for VEGF and Factor VIII (marker for vascular endothelial cells). Numbers of VEGF-immunoreactive (IR) cells and vascular density were examined. Walking duration was decreased after induction of cauda equina compression. The number of VEGF-IR cells in the cauda equina and DRG was significantly increased at 3, 14, and 28 days after cauda equina compression, compared with sham-operated rats (P < 0.05). Vascular density in the cauda equina was not increased at any of the time points examined. Cauda equina compression decreased walking duration, and induced VEGF expression in nerve roots and DRG.

An outcome measure for patients with cervical myelopathy: Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ): Part 1.

BACKGROUND: An outcome measure to evaluate the neurological function of cervical myelopathy was proposed by the Japanese Orthopaedic Association in 1975 (JOA score), and has been widely used in Japan. However, the JOA score does not include patients' satisfaction, disability, handicaps, or general health, which can be affected by cervical myelopathy. The purpose of this study was to develop a new outcome measure for patients with cervical myelopathy. METHODS: This study was conducted in eight university hospitals and their affiliated hospitals from February to May 2002. The questionnaire included 77 items. Forty-one questions, which were originally listed by the authors, were for evaluation of the physical function of the cervical spine and spinal cord. The Medical Outcome Study Short-Form 36-Item Health Survey (SF-36) was used to examine health-related quality of life (QOL). Patients with cervical myelopathy and healthy volunteers were recruited at each institution. After analysis of the answers from patients and volunteers, irrelevant questions using the following criteria were excluded: (1) a question 80% of answers for which were concentrated on one choice, (2) a question whose answer was highly correlated with that of other questions, (3) a question that could be explained by other questions, and (4) a question for which the distribution of the answers obtained from the patients was not different from that obtained from the normal volunteers. RESULTS: The patients comprised 164 men and 86 women, and the healthy volunteers 96 men and 120 women. Thirteen items from the questions about the physical functions of the cervical spine and the spinal cord and 11 items from SF-36 remained as candidates that should be included in the final outcome measure questionnaire. CONCLUSION: Twenty-four questions remained as candidates for the final questionnaire. This new self-administered questionnaire might be used to evaluate the outcomes in patients with cervical myelopathy more efficiently.