Acupuncture for chronic low back pain in older adults: Design and protocol for the BackInAction pragmatic clinical trial.

BACKGROUND: Back pain prevalence and burden increase with age; approximately one-third of U.S. adults 65 years of age and older experience lower back pain (LBP). For chronic low back pain (cLBP), typically defined as lasting three months or longer, many treatments for younger adults may be inappropriate for older adults given their greater prevalence of comorbidities with attendant polypharmacy. While acupuncture has been demonstrated to be safe and effective for cLBP in adults overall, few studies of acupuncture have either included or focused on adults ≥65 years old. METHODS: The BackInAction study is a pragmatic, multi-site, three-arm, parallel-groups randomized controlled trial designed to test the effectiveness of acupuncture needling for improving back pain-related disability among 807 older adults ≥65 years old with cLBP. Participants are randomized to standard acupuncture (SA; up to 15 treatment sessions across 12 weeks), enhanced acupuncture (EA; SA during first 12 weeks and up to 6 additional sessions across the following 12 weeks), and usual medical care (UMC) alone. Participants are followed for 12 months with study outcomes assessed monthly with the primary outcome timepoint at 6 months. DISCUSSION: The BackInAction study offers an opportunity to further understand the effectiveness, dose-dependence, and safety of acupuncture in a Medicare population. Additionally, study results may encourage broader adoption of more effective, safer, and more satisfactory options to the continuing over-reliance on opioid- and invasive medical treatments for cLBP among older adults. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04982315. Clinical trial registration date: July 29, 2021.

Stiffness of the human foot and evolution of the transverse arch.

The stiff human foot enables an efficient push-off when walking or running, and was critical for the evolution of bipedalism1-6. The uniquely arched morphology of the human midfoot is thought to stiffen it5-9, whereas other primates have flat feet that bend severely in the midfoot7,10,11. However, the relationship between midfoot geometry and stiffness remains debated in foot biomechanics12,13, podiatry14,15 and palaeontology4-6. These debates centre on the medial longitudinal arch5,6 and have not considered whether stiffness is affected by the second, transverse tarsal arch of the human foot16. Here we show that the transverse tarsal arch, acting through the inter-metatarsal tissues, is responsible for more than 40% of the longitudinal stiffness of the foot. The underlying principle resembles a floppy currency note that stiffens considerably when it curls transversally. We derive a dimensionless curvature parameter that governs the stiffness contribution of the transverse tarsal arch, demonstrate its predictive power using mechanical models of the foot and find its skeletal correlate in hominin feet. In the foot, the material properties of the inter-metatarsal tissues and the mobility of the metatarsals may additionally influence the longitudinal stiffness of the foot and thus the curvature-stiffness relationship of the transverse tarsal arch. By analysing fossils, we track the evolution of the curvature parameter among extinct hominins and show that a human-like transverse arch was a key step in the evolution of human bipedalism that predates the genus Homo by at least 1.5 million years. This renewed understanding of the foot may improve the clinical treatment of flatfoot disorders, the design of robotic feet and the study of foot function in locomotion.

In vivo force-length and activation dynamics of two distal rat hindlimb muscles in relation to gait and grade.

Muscle function changes to meet the varying mechanical demands of locomotion across different gait and grade conditions. A muscle's work output is determined by time-varying patterns of neuromuscular activation, muscle force and muscle length change, but how these patterns change under different conditions in small animals is not well defined. Here, we report the first integrated in vivo force-length and activation patterns in rats, a commonly used small animal model, to evaluate the dynamics of two distal hindlimb muscles (medial gastrocnemius and plantaris) across a range of gait (walk, trot and gallop) and grade (level and incline) conditions. We use these data to explore how the pattern of force production, muscle activation and muscle length changes across conditions in a small quadrupedal mammal. As hypothesized, we found that the rat muscles show limited fascicle strains during active force generation in stance across gaits and grades, indicating that these distal rat muscles generate force economically but perform little work, similar to patterns observed in larger animals during level locomotion. Additionally, given differences in fiber type composition and variation in motor unit recruitment across the gait and grade conditions examined here for these muscles, the in vivo force-length behavior and neuromuscular activation data reported here can be used to validate improved two-element Hill-type muscle models.

The Multi-Scale, Three-Dimensional Nature of Skeletal Muscle Contraction.

Muscle contraction is a three-dimensional process, as anyone who has observed a bulging muscle knows. Recent studies suggest that the three-dimensional nature of muscle contraction influences its mechanical output. Shape changes and radial forces appear to be important across scales of organization. Muscle architectural gearing is an emerging example of this process.

Structural Determinants of Muscle Gearing During Dynamic Contractions.

In skeletal muscle, interactions between contractile and connective tissue elements at multiple scales result in emergent properties that determine mechanical performance. One of these phenomena is architectural gearing, which is quantified as the ratio of muscle velocity to muscle fiber velocity. Many pennate muscles operate with a gear ratio greater than one because muscles shorten through a combination of muscle fiber shortening and fiber rotation. Within a muscle, gearing is variable across contractions. During low force contractions, muscles operate at high gear while muscles operate at low gear during high force contractions. This variable gearing has a significant impact on muscle performance as muscle architectural changes favor muscle speed during fast contractions and muscle force during slow, high force contractions. We hypothesize that gearing in any given contraction is determined by the dynamic interaction of fiber-generated forces, fluid force transmission, and the elastic behavior of intramuscular connective tissues. Because muscle is isovolumetric, muscle fibers must bulge radially when they shorten. Radial bulging and fiber-generated forces off-axis from the muscle line of action exert forces that load connective tissues that ensheath fibers, fascicles, and the whole muscle. The way in which fluid pressures and fiber forces interact to load connective tissues in three-dimensions remains poorly understood because of the complex and multiscale nature of these interactions. Here we review evidence for variable gearing in pennate muscles, present a conceptual model that describes the fundamental interactions that determine gearing, and discuss where gaps remain in our understanding of the determinants and consequences of muscle shape change and variable gearing.

Aponeurosis influences the relationship between muscle gearing and force.

Aponeuroses are connective tissues found on the surface of pennate muscles and are in close association with muscle fascicles. In addition to transmitting muscle forces to the external tendon, aponeurosis has been hypothesized to influence the direction of muscle shape change during a contraction. Muscle shape changes affect muscle contractile force and velocity because they influence the gear ratio with which muscle fascicles transmit force and velocity to the tendon. If aponeurosis modulates muscle shape changes, altering the aponeurosis' radial integrity with incisions should alter gearing. We tested the hypothesis that incising the aponeurosis would lead to decreased gearing across force conditions with an in situ preparation of the turkey lateral gastrocnemius muscle. We found that multiple full-length incisions in the aponeurosis altered the relationship between gearing and force relative to the intact aponeurosis condition. Specifically, after multiple aponeurosis incisions, gear ratio decreased by 19% in the high-force contractions compared with the intact condition. These results suggest that aponeuroses influence muscle shape change and can alter muscle contractile force and speed through their effect on muscle gearing. NEW & NOTEWORTHY Muscle gearing is determined by muscle shape change during a contraction and varies with the force of contraction. Variable gearing influences muscle force and speed, but how gearing is modulated is not well understood. Incising the aponeurosis before and after contractions demonstrates that aponeurosis plays a role in modulating gearing.

The capacity of the human iliotibial band to store elastic energy during running.

The human iliotibial band (ITB) is a poorly understood fascial structure that may contribute to energy savings during locomotion. This study evaluated the capacity of the ITB to store and release elastic energy during running, at speeds ranging from 2-5m/s, using a model that characterizes the three-dimensional musculoskeletal geometry of the human lower limb and the force-length properties of the ITB, tensor fascia lata (TFL), and gluteus maximus (GMax). The model was based on detailed analyses of muscle architecture, dissections of 3-D anatomy, and measurements of the muscles' moment arms about the hip and knee in five cadaveric specimens. The model was used, in combination with measured joint kinematics and published EMG recordings, to estimate the forces and corresponding strains in the ITB during running. We found that forces generated by TFL and GMax during running stretch the ITB substantially, resulting in energy storage. Anterior and posterior regions of the ITB muscle-tendon units (MTUs) show distinct length change patterns, in part due to different moment arms at the hip and knee. The posterior ITB MTU likely stores more energy than the anterior ITB MTU because it transmits larger muscle forces. We estimate that the ITB stores about 1J of energy per stride during slow running and 7J during fast running, which represents approximately 14% of the energy stored in the Achilles tendon at a comparable speed. This previously unrecognized mechanism for storing elastic energy may be an adaptation to increase human locomotor economy.

The human iliotibial band is specialized for elastic energy storage compared with the chimp fascia lata.

This study examines whether the human iliotibial band (ITB) is specialized for elastic energy storage relative to the chimpanzee fascia lata (FL). To quantify the energy storage potential of these structures, we created computer models of human and chimpanzee lower limbs based on detailed anatomical dissections. We characterized the geometry and force-length properties of the FL, tensor fascia lata (TFL) and gluteus maximus (GMax) in four chimpanzee cadavers based on measurements of muscle architecture and moment arms about the hip and knee. We used the chimp model to estimate the forces and corresponding strains in the chimp FL during bipedal walking, and compared these data with analogous estimates from a model of the human ITB, accounting for differences in body mass and lower extremity posture. We estimate that the human ITB stores 15- to 20-times more elastic energy per unit body mass and stride than the chimp FL during bipedal walking. Because chimps walk with persistent hip flexion, the TFL and portions of GMax that insert on the FL undergo smaller excursions (origin to insertion) than muscles that insert on the human ITB. Also, because a smaller fraction of GMax inserts on the chimp FL than on the human ITB, and thus its mass-normalized physiological cross-sectional area is about three times less in chimps, the chimp FL probably transmits smaller muscle forces. These data provide new evidence that the human ITB is anatomically derived compared with the chimp FL and potentially contributes to locomotor economy during bipedal locomotion.

Directional differences in the biaxial material properties of fascia lata and the implications for fascia function.

Fascia is a highly organized collagenous tissue that is ubiquitous in the body, but whose function is not well understood. Because fascia has a sheet-like structure attaching to muscles and bones at multiple sites, it is exposed to different states of multi- or biaxial strain. In order to measure how biaxial strain affects fascia material behavior, planar biaxial tests with strain control were performed on longitudinal and transversely oriented samples of goat fascia lata (FL). Cruciform samples were cycled to multiple strain levels while the perpendicular direction was held at a constant strain. Structural differences among FL layers were examined using histology and SEM. Results show that FL stiffness, hysteresis, and strain energy density are greater in the longitudinal vs. transverse direction. Increased stiffness in the longitudinal layer is likely due to its greater thickness and greater average fibril diameter compared to the transverse layer(s). Perpendicular strain did not affect FL material behavior. Differential loading in the longitudinal vs. transverse directions may lead to structural changes, enhancing the ability of the longitudinal FL to transmit force, store energy, or stabilize the limb during locomotion. The relative compliance of the transverse fibers may allow expansion of underlying muscles when they contract.

Comparison of rotator cuff muscle architecture between humans and other selected vertebrate species.

In this study, we compare rotator cuff muscle architecture of typically used animal models with that of humans and quantify the scaling relationships of these muscles across mammals. The four muscles that correspond to the human rotator cuff - supraspinatus, infraspinatus, subscapularis and teres minor - of 10 commonly studied animals were excised and subjected to a series of comparative measurements. When body mass among animals was regressed against physiological cross-sectional area, muscle mass and normalized fiber length, the confidence intervals suggested geometric scaling but did not exclude other scaling relationships. Based on the architectural difference index (ADI), a combined measure of fiber length-to-moment arm ratio, fiber length-to-muscle length ratio and the fraction of the total rotator cuff physiological cross-sectional area contributed by each muscle, chimpanzees were found to be the most similar to humans (ADI=2.15), followed closely by capuchins (ADI=2.16). Interestingly, of the eight non-primates studied, smaller mammals such as mice, rats and dogs were more similar to humans in architectural parameters compared with larger mammals such as sheep, pigs or cows. The force production versus velocity trade-off (indicated by fiber length-to-moment arm ratio) and the excursion ability (indicated by fiber length-to-muscle length ratio) of humans were also most similar to those of primates, followed by the small mammals. Overall, primates provide the best architectural representation of human muscle architecture. However, based on the muscle architectural parameters of non-primates, smaller rather than larger mammals may be better models for studying muscles related to the human rotator cuff.

Bite force and occlusal stress production in hominin evolution.

Maximum bite force affects craniofacial morphology and an organism's ability to break down foods with different material properties. Humans are generally believed to produce low bite forces and spend less time chewing compared with other apes because advances in mechanical and thermal food processing techniques alter food material properties in such a way as to reduce overall masticatory effort. However, when hominins began regularly consuming mechanically processed or cooked diets is not known. Here, we apply a model for estimating maximum bite forces and stresses at the second molar in modern human, nonhuman primate, and hominin skulls that incorporates skeletal data along with species-specific estimates of jaw muscle architecture. The model, which reliably estimates bite forces, shows a significant relationship between second molar bite force and second molar area across species but does not confirm our hypothesis of isometry. Specimens in the genus Homo fall below the regression line describing the relationship between bite force and molar area for nonhuman anthropoids and australopiths. These results suggest that Homo species generate maximum bite forces below those predicted based on scaling among australopiths and nonhuman primates. Because this decline occurred before evidence for cooking, we hypothesize that selection for lower bite force production was likely made possible by an increased reliance on nonthermal food processing. However, given substantial variability among in vivo bite force magnitudes measured in humans, environmental effects, especially variations in food mechanical properties, may also be a factor. The results also suggest that australopiths had ape-like bite force capabilities.

Plasticity of muscle architecture after supraspinatus tears.

STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To measure the architectural properties of rat supraspinatus muscle after a complete detachment of its distal tendon. METHODS: Supraspinatus muscles were released from the left humerus of 29 Sprague-Dawley rats (mass, 400-450 g), and the animals were returned to cage activity for 2 weeks (n=12), 4 weeks (n=9), or 9 weeks (n=8), before euthanasia. Measurements of muscle mass, pennation angle, fiber bundle length (sarcomere number), and sarcomere length permitted calculation of normalized fiber length, serial sarcomere number, and physiological cross-sectional area. RESULTS: Coronal oblique sections of the supraspinatus confirmed surgical transection of the supraspinatus muscle at 2 weeks, with reattachment by 4 weeks. Muscle mass and length were significantly lower in released muscles at 2 weeks, 4 weeks, and 9 weeks. Sarcomere lengths in released muscles were significantly shorter at 2 weeks but not different by 4 weeks. Sarcomere number was significantly reduced at 2 and 4 weeks, but returned to control values by 9 weeks. The opposing effects of smaller mass and shorter fibers produced significantly smaller physiological cross-sectional area at 2 weeks, but physiological cross-sectional area returned to control levels by 4 weeks. CONCLUSIONS: Release of the supraspinatus muscle produced early radial and longitudinal atrophy of the muscle. The functional implications of these adaptations would be most profound at early time points (particularly relevant for rehabilitation), when the muscle remains smaller in cross-sectional area and, due to reduced sarcomere number, would be forced to operate over a wider range of the length-tension curve and at higher velocities, all adaptations resulting in compromised force-generating capacity. These data are relevant to physical therapy because they provide tissue-level insights into impaired muscle and shoulder function following rotator cuff injury.

Architectural analysis and intraoperative measurements demonstrate the unique design of the multifidus muscle for lumbar spine stability.

BACKGROUND: Muscular instability is an important risk factor for lumbar spine injury and chronic low-back pain. Although the lumbar multifidus muscle is considered an important paraspinal muscle, its design features are not completely understood. The purpose of the present study was to determine the architectural properties, in vivo sarcomere length operating range, and passive mechanical properties of the human multifidus muscle. We hypothesized that its architecture would be characterized by short fibers and a large physiological cross-sectional area and that it would operate over a relatively wide range of sarcomere lengths but would have very stiff passive material properties. METHODS: The lumbar spines of eight cadaver specimens were excised en bloc from T12 to the sacrum. Multifidus muscles were isolated from each vertebral level, permitting the architectural measurements of mass, sarcomere length, normalized fiber length, physiological cross-sectional area, and fiber length-to-muscle length ratio. To determine the sarcomere length operating range of the muscle, sarcomere lengths were measured from intraoperative biopsy specimens that were obtained with the spine in the flexed and extended positions. The material properties of single muscle fibers were obtained from passive stress-strain tests of excised biopsy specimens. RESULTS: The average muscle mass (and standard error) was 146 +/- 8.7 g, and the average sarcomere length was 2.27 +/- 0.06 microm, yielding an average normalized fiber length of 5.66 +/- 0.65 cm, an average physiological cross-sectional area of 23.9 +/- 3.0 cm(2), and an average fiber length-to-muscle length ratio of 0.21 +/- 0.03. Intraoperative sarcomere length measurements revealed that the muscle operates from 1.98 +/- 0.15 microm in extension to 2.70 +/- 0.11 microm in flexion. Passive mechanical data suggested that the material properties of the muscle are comparable with those of muscles of the arm or leg. CONCLUSIONS: The architectural design (a high cross-sectional area and a low fiber length-to-muscle length ratio) demonstrates that the multifidus muscle is uniquely designed as a stabilizer to produce large forces. Furthermore, multifidus sarcomeres are positioned on the ascending portion of the length-tension curve, allowing the muscle to become stronger as the spine assumes a forward-leaning posture.

The functional correlates of jaw-muscle fiber architecture in tree-gouging and nongouging callitrichid monkeys.

Common (Callithrix jacchus) and pygmy (Cebuella pygmaea) marmosets and cotton-top tamarins (Saguinus oedipus) share broadly similar diets of fruits, insects, and tree exudates. Marmosets, however, differ from tamarins in actively gouging trees with their anterior dentition to elicit tree exudates flow. Tree gouging in common marmosets involves the generation of relatively wide jaw gapes, but not necessarily relatively large bite forces. We compared fiber architecture of the masseter and temporalis muscles in C. jacchus (N = 18), C. pygmaea (N = 5), and S. oedipus (N = 13). We tested the hypothesis that tree-gouging marmosets would exhibit relatively longer fibers and other architectural variables that facilitate muscle stretch. As an architectural trade-off between maximizing muscle excursion/contraction velocity and muscle force, we also tested the hypothesis that marmosets would exhibit relatively less pinnate fibers, smaller physiologic cross-sectional areas (PCSA), and lower priority indices (I) for force. As predicted, marmosets display relatively longer-fibered muscles, a higher ratio of fiber length to muscle mass, and a relatively greater potential excursion of the distal tendon attachments, all of which favor muscle stretch. Marmosets further display relatively smaller PCSAs and other features that reflect a reduced capacity for force generation. The longer fibers and attendant higher contraction velocities likely facilitate the production of relatively wide jaw gapes and the capacity to generate more power from their jaw muscles during gouging. The observed functional trade-off between muscle excursion/contraction velocity and muscle force suggests that primate jaw-muscle architecture reflects evolutionary changes related to jaw movements as one of a number of functional demands imposed on the masticatory apparatus.

Are current measurements of lower extremity muscle architecture accurate?

Skeletal muscle architecture is defined as the arrangement of fibers in a muscle and functionally defines performance capacity. Architectural values are used to model muscle-joint behavior and to make surgical decisions. The two most extensively used human lower extremity data sets consist of five total specimens of unknown size, gender, and age. Therefore, it is critically important to generate a high-fidelity human lower extremity muscle architecture data set. We disassembled 27 muscles from 21 human lower extremities to characterize muscle fiber length and physiologic cross-sectional area, which define the excursion and force-generating capacities of a muscle. Based on their architectural features, the soleus, gluteus medius, and vastus lateralis are the strongest muscles, whereas the sartorius, gracilis, and semitendinosus have the largest excursion. The plantarflexors, knee extensors, and hip adductors are the strongest muscle groups acting at each joint, whereas the hip adductors and hip extensors have the largest excursion. Contrary to previous assertions, two-joint muscles do not necessarily have longer fibers than single-joint muscles as seen by the similarity of knee flexor and extensor fiber lengths. These high-resolution data will facilitate the development of more accurate musculoskeletal models and challenge existing theories of muscle design; we believe they will aid in surgical decision making.

Scaling of muscle architecture and fiber types in the rat hindlimb.

The functional capacity of a muscle is determined by its architecture and metabolic properties. Although extensive analyses of muscle architecture and fiber type have been completed in a large number of muscles in numerous species, there have been few studies that have looked at the interrelationship of these functional parameters among muscles of a single species. Nor have the architectural properties of individual muscles been compared across species to understand scaling. This study examined muscle architecture and fiber type in the rat (Rattus norvegicus) hindlimb to examine each muscle's functional specialization. Discriminant analysis demonstrated that architectural properties are a greater predictor of muscle function (as defined by primary joint action and anti-gravity or non anti-gravity role) than fiber type. Architectural properties were not strictly aligned with fiber type, but when muscles were grouped according to anti-gravity versus non-anti-gravity function there was evidence of functional specialization. Specifically, anti-gravity muscles had a larger percentage of slow fiber type and increased muscle physiological cross-sectional area. Incongruities between a muscle's architecture and fiber type may reflect the variability of functional requirements on single muscles, especially those that cross multiple joints. Additionally, discriminant analysis and scaling of architectural variables in the hindlimb across several mammalian species was used to explore whether any functional patterns could be elucidated within single muscles or across muscle groups. Several muscles deviated from previously described muscle architecture scaling rules and there was large variability within functional groups in how muscles should be scaled with body size. This implies that functional demands placed on muscles across species should be examined on the single muscle level.

Muscle geometry affects accuracy of forearm volume determination by magnetic resonance imaging (MRI).

Upper extremity musculoskeletal modeling is becoming increasingly sophisticated, creating a growing need for subject-specific muscle size parameters. One method for determining subject-specific muscle volume is magnetic resonance imaging (MRI). The purpose of this study was to determine the validity of MRI-derived muscle volumes in the human forearm across a variety of muscle sizes and shapes. Seventeen cadaveric forearms were scanned using a fast-spoiled gradient echo pulse sequence with high isotropic spatial resolution (1mm(3) voxels) on a 3T MR system. Pronator teres (PT), extensor carpi radialis brevis (ECRB), extensor pollicis longus (EPL), flexor carpi ulnaris (FCU), and brachioradialis (BR) muscles were manually segmented allowing volume to be calculated. Forearms were then dissected, muscles isolated, and muscle masses obtained, which allowed computation of muscle volume. Intraclass correlation coefficients (ICC(2,1)) and absolute volume differences were used to compare measurement methods. There was excellent agreement between the anatomical and MRI-derived muscle volumes (ICC = 0.97, relative error = 12.8%) when all 43 muscles were considered together. When individual muscles were considered, there was excellent agreement between measurement methods for PT (ICC = 0.97, relative error = 8.4%), ECRB (ICC = 0.93, relative error = 7.7%), and FCU (ICC = 0.91, relative error = 9.8%), and fair agreement for EPL (ICC = 0.68, relative error = 21.6%) and BR (ICC = 0.93, relative error = 17.2%). Thus, while MRI-based measurements of muscle volume produce relatively small errors in some muscles, muscles with high surface area-to-volume ratios may predispose them to segmentation error, and, therefore, the accuracy of these measurements may be unacceptable.