Widespread pain in chronic epicondylitis.

We studied the associations of widespread pain with other pain and functional measures among patients with chronic epicondylitis. A total of 190 patients (66% females) participated in the study; with a mean age 43.7, mean duration of symptoms 48weeks, chronic lateral (n=160) and medial (n=30) epicondylitis. We analysed clinical status, grip strength and cubital pain thresholds and interviewed pain and disability, leisure time physical activity, strenuous hobby activities for arms, duration of symptoms, other systemic and upper extremity disorders, arm operations, and work ability. The location of pain was analysed using a whole-body pain drawing, categorized into three groups; the highest of which was classified as widespread pain. A total of 85 patients (45%) reported widespread pain. It was highly associated with female gender, high pain scores, decreased grip strength and pain thresholds (p<0.001 for all), with increased number of positive manual tests, low level of hobby strain for arms and physical activity, long duration of symptoms, and sick leave (p for all <0.05). It was also related to upper extremity disorders and arm surgery, but not with operated epicondylitis, other systemic diseases, workload or work ability. In addition, 39% of patients without other disease reported widespread pain. Widespread pain is common in chronic epicondylitis with and without other diseases, and is related to high pain scores, decreased function of the arm, long duration of symptoms, sick leave, and with a low level of physical activity.

Is the interleukin-6 haplotype a prognostic factor for sciatica?

AIMS: We have shown in a cross-sectional setting that an IL6 haplotype (GGGA) is associated with intervertebral disc disease (IDD) characterized by sciatica. The aim of this study was to evaluate the prognostic role of the GGGA haplotype in IDD. METHODS: DNA from 153 sciatica patients who participated in a randomized controlled trial of periradicular infiltration was analysed for IL6 variations rs1800797 (-596A>G), rs1800796 (-572G>C), rs1800795 (-174G>C), and rs13306435 (+15T>A). The patients recorded back and leg pain intensity and duration, disability by Oswestry Index and back-related sickness absence over a three-year follow-up. Repeated measures and univariate analysis of variance with adjustment for age, gender and physical work load were used in statistical analyses for the last two-years of the follow-up. RESULTS: The prevalence of the GGGA haplotype was 9% (14/153). Subjects with the GGGA haplotype did not differ from those without the haplotype with respect to pain intensity, or disability score, but days with back and leg pain and days on sick leave were significantly higher among subjects with the IL6 haplotype after adjustment for occupation (p=0.006, 0.001 and 0.002, respectively). An interaction between the IL6 haplotype and physical work load was significant for the duration of back and leg pain and sick leave (p=0.038, 0.011 and 0.006, respectively). CONCLUSIONS: This is the first observation of any prognostic genotype among sciatica patients. The IL6 haplotype GGGA predicted the number of days with back or leg pain and also sickness absence. Subjects with the IL6 haplotype may be more vulnerable when doing physically demanding jobs.

A three-year follow-up of lumbar spine endplate (Modic) changes.

STUDY DESIGN: A longitudinal follow-up of Modic changes on magnetic resonance imaging (MRI). OBJECTIVES: To assess the prevalence and natural course Modic changes over a 3-year follow-up period. SUMMARY OF BACKGROUND DATA: Modic changes are bone marrow and endplate lesions visible on MRI. To the authors' knowledge, no follow-up studies on their natural course have been published. METHODS: The study population consisted of 60 unoperated sciatica patients 23 to 76 years of age. Baseline and 3-year lumbar MR images from L1-L2 through L5-S1 were analyzed independently by 2 radiologists and a consensus reading was performed. RESULTS: At baseline, the prevalence of Modic changes was 23%. Seven discs had mixed Type I/II, and 63 Type II change. Changes typically occurred at L4-L5 and L5-S1, and associated positively with age (P = 0.009). Ten of 70 discs (14%) with Modic changes at baseline displayed another type at 3 years. Furthermore, the nonconverted changes increased significantly in size. The incidence of new Modic changes during the follow-up was 6% (13 of 230). CONCLUSIONS: Modic changes are common MRI findings in patients with degenerative lumbar disc disease. We found evidence that Modic Type II changes may be less stable than previously assumed.

Determinants of spontaneous resorption of intervertebral disc herniations.

STUDY DESIGN: A follow-up of disc herniation (herniated nucleus pulposus [HNP]) resorption on magnetic resonance imaging (MRI). OBJECTIVE: To assess the determinants of resorption of HNP. SUMMARY OF BACKGROUND DATA: Neovascularization in the outermost areas of HNP, presenting as an enhancing rim in gadolinium diethylenetriamine pentaacetic acid MR images, is thought to be a major determinant of spontaneous resorption of HNP. METHODS: Patients with HNP-induced sciatica at baseline were rescanned at 2 months (N = 74) and after 12 months (N = 53). The volume of HNP (mm), thickness (mm) and extent (%) of enhancement, and the degree of HNP migration (Komori classification) were analyzed. Repeated measures analysis of covariance was used in statistical analysis. RESULTS: Significant resorption of HNP occurred from baseline to 2 months, although the resorption rate was more pronounced over the whole 1-year follow-up. Higher baseline scores of rim enhancement thickness, higher degree of HNP displacement in the Komori classification, and age category 41-50 years were associated with a higher resorption rate. Thickness of rim enhancement was a stronger determinant of spontaneous resorption than extent of rim enhancement. Clinical symptom alleviation occurs concordantly with a faster resorption rate. CONCLUSIONS: MRI is a useful prognostic tool for identifying patients with HNP-induced sciatica with a benign natural course.

Growth factor expression in degenerated intervertebral disc tissue. An immunohistochemical analysis of transforming growth factor beta, fibroblast growth factor and platelet-derived growth factor.

Degenerated intervertebral disc has lost its normal architecture, and there are changes both in the nuclear and annular parts of the disc. Changes in cell shape, especially in the annulus fibrosus, have been reported. During degeneration the cells become more rounded, chondrocyte-like, whereas in the normal condition annular cells are more spindle shaped. These chondrocyte-like cells, often forming clusters, affect extracellular matrix turnover. In previous studies transforming growth factor beta (TGFbeta) -1 and -2, basic fibroblast growth factor (bFGF) and platelet-derived growth factor (PDGF) have been highlighted in herniated intervertebral disc tissue. In the present study the same growth factors are analysed immunohistochemically in degenerated intervertebral disc tissue. Disc material was obtained from 16 discs operated for painful degenerative disc disease. Discs were classified according to the Dallas Discogram Description. Different disc regions were analysed in parallel. As normal control disc tissue material from eight organ donors was used. Polyclonal antibodies against different growth factors and TGFbeta receptor type II were used, and the immunoreaction was detected by the avidin biotin complex method. All studied degenerated discs showed immunoreactivity for TGFbeta receptor type II and bFGF. Fifteen of 16 discs were immunopositive for TGFbeta-1 and -2, respectively, and none showed immunoreaction for PDGF. Immunopositivity was located in blood vessels and in disc cells. In the nucleus pulposus the immunoreaction was located almost exclusively in chondrocyte-like disc cells, whereas in the annular region this reaction was either in chondrocyte-like disc cells, often forming clusters, or in fibroblast-like disc cells. Chondrocyte-like disc cells were especially prevalent in the posterior disrupted area. In the anterior area of the annulus fibrosus the distribution was more even between these two cell types. bFGF was expressed in the anterior annulus fibrosus more often in chondrocyte-like disc cells than in fibroblast-like disc cells. Control discs showed cellular immunopositivity for only TGFbeta-1 and -2 and TGFbeta receptor type II . We suggest that growth factors create a cascade in intervertebral disc tissue, where they act and participate in cellular remodelling from the normal resting stage via disc degeneration to disc herniation.

Back and neck extensor loading and back pain provocation in urban bus drivers with and without low back pain.

This study assessed low back and trapezius muscle activity in bus drivers, with or without recurrent low back pain (LBP), during the long term driving. In addition, low back and neck-shoulder pain intensities and fatigue were measured and the effect of low back support was observed. Also the possible source of LBP was attempted to assess by vibration pain provocation test and lumbar MRI. Forty bus drivers (recurrent LBP n = 25) participated in this study. Low back and neck-shoulder pain and subjective fatigue intensity was assessed by visual analogue scales (VAS) before and after driving. Lumbar paraspinal and trapezius muscle activation during driving was measured by surface EMG. Vibration pain provocation test was applied for all subjects. Average paraspinal myoelectric activity during driving was approximately 1% of MVC in both groups. Average trapezius myoelectric activity during driving was from 2 to 4% of MVC. Trapezius muscle activity was higher in back healthy drivers than in those with LBP. The low back support had no effect either on paraspinal or trapezius EMG activity. Low back and neck-shoulder fatigue increased during driving in both groups especially in those subjects with positive vibration pain provocation. The neck-shoulder pain and fatigue were more severe in drivers suffering from LBP. Low back support had no effect on low back and neck-shoulder subjective fatigue and neck-shoulder pain but tended to limit the LBP increase during driving. Paraspinal muscle loading in urban bus drivers was very limited and either LBP or ergonomic low back support had no effect on it. Trapezius muscle seemed to be less active in drivers suffering from recurrent LBP. Internal disc disruptions may expose to pain and fatigability during driving.

Effects of a workplace physical exercise intervention on the intensity of headache and neck and shoulder symptoms and upper extremity muscular strength of office workers: a cluster randomized controlled cross-over trial.

The purpose of the study was to examine the effects of a workplace physical exercise intervention on the perceived intensity of headache and the intensity of symptoms in the neck and shoulders, as well as on the extension and flexion strength of the upper extremities. The study was a cluster randomized controlled trial. The cross-over design consisted of physical exercise intervention (15 weeks) and no-intervention (15 weeks). The subjects (n=53) were office workers (mean age 46.6 (SD 8.4)) who reported headache (n=41) symptoms in the neck (n=37) or shoulders (n=41), which had restricted their daily activities during the last 12 months. Pain symptoms were measured using the Borg CR10 scale and muscular strength with a 5RM test. Statistical analyses were based on linear mixed models. Physical exercise intervention resulted in a slight, but statistically significant, decrease in the intensity of headache and neck symptoms, as well as an increase in the extension strength of the upper extremities. The mean decrease in headache during the 5-week period was 0.64 CR10 (95% CI 0.28-1.00) (P=0.001) or 49% (95% CI 22-77), and 0.42 CR10 (95% CI 0.11-0.72) (P=0.002) or 49% (95% CI 13-85) in the intensity of neck symptoms. The mean increase in the extension strength of the upper extremities was 1.3 kg (95% CI 0.5-2.1) (P=0.001) or 4% (95% CI 1-6). The intervention had no effect on the intensity of shoulder symptoms or the flexion strength of the upper extremities. Specific exercise may be clinically important to alleviate headache and neck symptoms.

Determinants of lumbar artery occlusion among patients with sciatica: a three-year follow-up with magnetic resonance angiography.

We showed previously that chronic Chlamydia pneumoniae infection increases the risk of lumbar artery occlusion. We did not evaluate, however, the effect of other risk factors for cardiovascular diseases in combination with this chronic infection. The purpose of this study was to investigate the combined effect of chronic C. pneumoniae infection and other known determinants of artery occlusion in a population of sciatica patients. Two-dimensional time-of-flight magnetic resonance angiography (MRA) was used to evaluate lumbar arteries at baseline and three years. The arteries on both sides (L1-L4) were evaluated visually and scored as normal, narrowed or occluded. Logistic regression analysis was performed separately for baseline total arterial stenosis and each L1-L4 segmental artery pair, and for incident new stenosis during the follow-up period. The determinants analyzed included age, body mass index (BMI, kg/m(2)), education, gender, and smoking, in addition to presence of chronic C. pneumoniae infection. MRA was obtained at baseline for 147 patients and at 3 years for 134 patients. Sixty-four (47.8%) of 134 patients had new arterial stenosis. Total incidence of new arterial stenosis was distributed quite evenly between the individual segmental levels, varying from 12.7 to 18.6%. BMI was the only predictor of new arterial stenosis (odds ratio (OR) 1.13). A reasonable logistic model could be established only for baseline L4 and total arterial scores. At L4, education was a protective factor (OR 0.07), whereas age (OR for the oldest age group 6.7) and BMI (OR 1.17) were associated with increased risk of occlusion. For total arterial score, chronic C. pneumoniae infection was an independent determinant of arterial occlusion, increasing the risk to almost eightfold. Additionally, BMI (OR 1.16), and age (for the oldest age group OR 11.4) were significant determinants for stenosis. Smoking was not statistically significant. As chronic C. pneumoniae infection was an independent determinant of lumbar artery occlusion, treatments of this chronic infection may have an impact on lumbar diseases. The importance of BMI for new arterial stenosis suggests that weight reduction may also have a beneficial effect in lumbar artery disease.

Three-year follow-up of lumbar artery occlusion with magnetic resonance angiography in patients with sciatica: associations between occlusion and patient-reported symptoms.

STUDY DESIGN: Comparison of occlusion of lumbar arteries in magnetic resonance angiography (MRA) with patient-reported sciatica symptoms during a 3-year follow-up. OBJECTIVES: To evaluate whether occlusion of lumbar arteries is associated with subjective pain symptoms and physical ability among sciatica patients. SUMMARY OF BACKGROUND DATA: Cadaveric studies indicate that atherosclerotic manifestations of the abdominal aorta are associated with low back pain (LBP). Impaired blood flow may disturb diffusion of nutrients into the disc, causing degeneration and possibly back pain. METHODS: Two-dimensional time-of-flight MRA was used to evaluate lumbar arteries at baseline and 3 years. The arteries on both sides (L1-L4) were evaluated visually and scored as normal, narrowed, or occluded. Incidence of new stenosis was estimated. The associations of stenosis with self-reported previous medical consultations, pain duration through the first year, and number of pain episodes through the last 2 years of follow-up were calculated. Additionally, leg and back pain (10-cm VAS), disability (Oswestry), and self-reported physical ability (self-efficacy) were inquired at 1, 2, and 3 years. In the statistical analysis, bivariate correlation, and the chi or Fisher's test were used. RESULTS: MRA was obtained at baseline for 147 patients and at 3 years for 134 patients. Baseline stenosis associated with intensity of back pain at 1 year, leg pain at 2 years, and self-efficacy at every follow-up assessment, but not with disability, previous LBP history, or future pain episodes. The associations of stenosis at 3 years were similar but weaker. Newly formed stenosis was associated with the preceding year's medical consultations due to LBP and prolonged LBP during the first follow-up year. CONCLUSIONS: Arterial stenosis is associated strongly and consistently with patient-estimated physical ability,but only slightly with subjective pain symptoms. Interestingly, new stenosis is preceded by pain symptoms. The evaluation of lumbar blood flow may thus be useful in clinical practice.

Effect of periradicular methylprednisolone on spontaneous resorption of intervertebral disc herniations.

STUDY DESIGN: Prospective comparison of periradicular infiltration with steroid versus saline on the spontaneous resorption of herniated nucleus pulposus in a randomized controlled trial. OBJECTIVES: To evaluate whether periradicular steroid retards the resorption of herniated nucleus pulposus. SUMMARY OF BACKGROUND DATA: Rim enhancement around herniated nucleus pulposus is associated with spontaneous resorption of disc herniations. As rim enhancement consists of a macrophage infiltrate, periradicular steroid could theoretically interfere with the resorption process. METHODS.: Patients with disc herniation-induced sciatica were randomized to receive either periradicular methylprednisolone (in combination with bupivacaine) or saline. Lumbar magnetic resonance imaging (MRI) was performed at baseline, at 2 months, and at 12 months. Disc herniation volume (mm3), coverage of rim enhancement (%), and rim enhancement thickness (mm) were evaluated by a radiologist blinded to the allocation. Operated patients were excluded from the 1-year imaging. Changes in the parameters from baseline to 2 months, and from 2 to 12 months, were evaluated with the Mann-Whitney U test. RESULTS: Change in herniation volume from baseline to 2 months was measurable in 34 patients of both groups, and from 2 to 12 months in 26 patients of the steroid group and 24 patients of the saline group. Significant spontaneous resorption of disc herniations occurred in both groups during the 1-year follow-up. In the subgroup analysis, there tended to be even faster resorption in the steroid group from baseline to 2 months for extrusions, and from 2 months to 12 months for contained herniations. No significant differences were observed in the enhancement parameters (coverage and thickness) between the two treatments. CONCLUSIONS: Periradicular corticosteroid does not have a negative effect on the spontaneous resorption of the herniated nucleus pulposus.

Predictive factors for neck and shoulder pain: a longitudinal study in young adults.

STUDY DESIGN: A longitudinal study. OBJECTIVES: To estimate the prevalence and incidence of neck and shoulder pain in young adults and to identify the associated and predictive factors of neck and shoulder pain based on 7-year follow-up. SUMMARY OF BACKGROUND DATA: Several work-related, psychosocial, and sociodemographic factors have been verified as being related to neck and shoulder pain in adult populations, but far fewer longitudinal studies concerning the topic have been carried out in young populations. METHODS: A random sample of 826 high school students was investigated when they were 15 to 18 years old and again at 22 to 25 years of age. Altogether, 394 (48%) patients participated in both surveys. The outcome variable was weekly neck and shoulder pain during the past 6 months in adulthood, and the explanatory variables included some sociodemographic factors, leisure time activities, self-assessed physical condition, psychosomatic stress symptoms, and symptoms of fatigue and sleep difficulties. RESULTS: In 7 years, the prevalence of weekly neck and shoulder pain increased from 17% to 28%. Among those who were asymptomatic at baseline, 6-month incidence of occasional or weekly neck and shoulder pain was 59% 7 years later. In an adjusted model, psychosomatic symptoms remained an associated factor for prevalent neck and shoulder pain 7 years later for both females and males. In females, neck and shoulder pain in adolescence was associated with prevalent neck and shoulder pain in adulthood, and sports loading dynamically in the upper extremities was an associated factor for a low prevalence of neck and shoulder pain 7 years later. In separate analyses of incident neck and shoulder pain, psychosomatic stress symptoms predicted neck and shoulder pain in adulthood. CONCLUSIONS: In young adults, the incidence of neck and shoulder pain is high, and the associated factors of neck and shoulder pain are already multifactorial in a young population.

Chronic Chlamydia pneumoniae infection increases the risk of occlusion of lumbar segmental arteries of patients with sciatica: a 3-year follow-up study.

STUDY DESIGN: A magnetic resonance imaging follow-up study of lumbar arteries among patients with sciatica with chronic Chlamydia pneumoniae infection. OBJECTIVE: To determine whether chronic infection causes occlusion of lumbar arteries. SUMMARY OF BACKGROUND DATA: C. pneumoniae infection is associated with coronary heart disease, and the infectious pathogen has also been detected in abdominal aortic aneurysms and in atherosclerotic plaques. No studies are available on the effect of this infectious agent on lumbar arteries. METHODS: Chronic infection was defined as persistent high positive immunoglobulin G and/or immunoglobulin A antibodies and/or the presence of immune complexes. The lumbar arteries, evaluated with two-dimensional time-of-flight magnetic resonance angiography, were scored as normal, narrowed, or occluded. The differences in the segmental and whole lumbar spine (segments L1-L4) sum of arterial occlusion at baseline and at 3 years, and the incidence of new arterial stenosis were compared in patients with and without chronic infection using the Kolmogorov-Smirnov test. RESULTS: Patients with chronic infection were more likely to be persistent smokers (P = 0.006), male (P = 0.04), and more obese (P = 0.02) compared to patients with normal antibody levels. They had significantly higher degree of arterial stenosis at L4 segment at baseline and at 3 years (P = 0.001 and 0.002, respectively), in the whole lumbar spine at baseline and at 3 years (P < 0.001 for both), and at L1 and L3 segments at 3 years (P = 0.013 for both). The incidence of new arterial stenosis was similar in both patient groups. Patients with chronic infection also had significantly higher grade of endplate degeneration at L4-L5 (P = 0.008). CONCLUSIONS: The results of this study suggest that chronic C. pneumoniae infection may induce stenosis of lumbar arteries.

The relationship between anthropometric factors and body-balancing movements in postural balance.

OBJECTIVE: To evaluate the relationship between anthropometric characteristics and body-balancing movements when standing on 2 legs with eyes open and eyes closed. DESIGN: Cross-sectional. SETTING: A university physiatry laboratory. PARTICIPANTS: One hundred randomly selected subjects (50 men, 50 women; age range, 31-80y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Anthropomorphic: body height, weight, lower-extremity distances, foot lengths, and widest widths of the forefeet and heels. Body movements: 2-legged stance with eyes open and eyes closed, measured with the MacReflex Motion Capture System and calculated as maximal and total movements in 3 dimensions. The relation between the measured anthropometric characteristics and body-balancing movements was calculated by using regression analysis. RESULTS: In the eyes-open condition, maximal lateral knee movement was related to body height and foot length (R(2)=.065, P<.05). Both anteroposterior (AP) head movement (R(2)=.068, P<.05) and AP navel movement (R(2)=.083, P<.05) were related to heel width. AP knee movement was related to foot length and heel width (R(2)=.089, P<.05). Body mass index was related to AP ankle movement (R(2)=.074, P<.05) and to vertical ankle movement (R(2)=.063, P<.05). In the eyes-closed condition, body mass index was related to the vertical navel movement (R(2)=.059, P<.05) and body height to AP knee movement (R(2)=.041, P<.05). CONCLUSION: The levels of significance are not high but warrant attention. It seems that there was no single anthropometric factor that explained the variations in body-balancing movements during standing.

Radiologic phenotypes in lumbar MR imaging for a gene defect in the COL9A3 gene of type IX collagen.

PURPOSE: To evaluate whether the COL9A3 tryptophan allele (Trp3 allele) is associated with a specific radiologic phenotype among patients with sciatica. MATERIALS AND METHODS: One hundred fifty-three patients with sciatica were evaluated for the presence of Trp3 allele, Scheuermann disease, intervertebral disk degeneration, Schmorl nodules, dorsal anular tears, hyperintense lesions, and endplate degeneration on sagittal T2-weighted lumbar magnetic resonance images. The Trp3 genotype was determined by means of sequencing the COL9A3 gene. Radiologic phenotypes were evaluated while blinded to the genotype. Scheuermann disease was diagnosed if either endplate irregularities or Schmorl nodules and two of the other three criteria (disk space narrowing, disk dehydration, and wedging of anterior vertebral body margins) were present at three or more adjacent disk levels from T10-11 to L3-4. Disk degeneration was evaluated separately for each disk (T11-12 to L5-S1) and for all disks combined. Frequencies of radiologic phenotypes between individuals with or without Trp3 allele were compared. RESULTS: Thirty-four patients had at least one Trp3 allele. When compared with the matched control subjects, they had an increased likelihood of Scheuermann disease (P =.035) and an increased number of degenerated disks from T11 to S1 (P =.021). Comparisons at individual disks showed a statistically significant increase in disk degeneration at T11-12 (analysis of all grades of degeneration [graded], P =.018; analysis of any degeneration vs none [dichotomous], P =.039) and L4-5 (graded, P =.011; dichotomous, P =.016). Prevalences of anular tears, endplate degeneration, Schmorl nodules, and hyperintense lesions were comparable. CONCLUSION: The results of this study indicate that the presence of Trp3 allele is associated with Scheuermann disease and intervertebral disk degeneration. No associations were found for other radiologic phenotypes.

Complement membrane attack complexes in pathologic disc tissues.

STUDY DESIGN: Complement membrane attack complexes were located in lumbar spine disc tissues by immunohistochemistry. Their occurrence was compared in control discs obtained from organ donors (CD), discs showing a normal macroscopic anatomy, samples of intervertebral disc herniations (DH), and intervertebral discs found to be degenerated by discography, but not herniated (DD). OBJECTIVE: To look for a possible role of complement activation, specifically complement membrane attack complexes, an end product of the classic immune complex-mediated complement activation pathway, in disc pathophysiology. SUMMARY OF BACKGROUND DATA: Recent immunohistochemical and biochemical studies suggest a possible role for immune complexes, as observed by immunohistochemical location and biochemical assay of immunoglobulins M and G in intervertebral disc pathophysiology. Immune complexes may trigger complement activation and ultimately cell lysis. There are, however, currently no reports on complement activation in disc tissues, although immune (antigen-antibody) complexes have been demonstrated. Such immune complexes have been reported to occur on or near to disc cells in DH tissues. METHODS: Thin frozen sections of disc tissue from CD (n = 9 discs), DH (n = 58 discs), and DD (n = 11 discs) were cut and then immunostained with a monoclonal antibody to the complement membrane attack complex (C5b-9) using avidin-biotin complex (ABC) immunostaining. The presence or absence of complement membrane attack complex immunoreactivity was compared in the various subtypes of DH and also with preoperative duration of radicular pain. RESULTS: Complement membrane attack complexes could be observed in none of the CDs studied. In contrast, in more than one third of both the DH (21/58, 36.2%) and the DD (4/11, 36.4%), immunoreactivity to complement membrane attack complexes could be observed in disc cells. In DD discs, immunoreactivity to complement membrane attack complexes was most often present in anulus fibrosus samples (5/13, 38.5%). With respect to subtype of DH, complement membrane attack complexes were observed in 19 of 36 sequestrated discs (52.8%), 1 of 16 extrusions (6.3%), and 1 of 6 protrusions (16.7%). Complement membrane attack complexes were more often present with shorter pain duration (P= 0.03), but showed no relation to age. Disc cells often showed a heavy staining pattern for complement membrane attack complexes, suggesting an abundance of these complexes lodged in the membrane of the cells. CONCLUSIONS: The predominant presence of complement membrane attack complexes in sequestrated disc tissue could suggest a role in DH tissue-induced sciatica. Possibly immune (antigen-antibody) complexes, reported in previous studies, trigger the classic pathway of complement activation, with complement membrane attack complexes as the final product. Complement membrane attack complexes also appear to have some as yet undefined role in degenerated nonherniated disc tissue, with a predominant presence in the anulus fibrosus cells of such discs.

Motion analysis measurements of body movements during standing: association with age and sex.

The purpose of this study was to evaluate the association between balancing movements and age and sex in standing on two legs with the eyes open and closed using the motion analysis system. The collected data may help in developing balance evaluation and training in rehabilitation. The study sample consisted of 100 healthy, randomly selected people from the City of Oulu (men and women aged 31 to 80 years). The participants were divided into 10 groups by age decade and sex. The body movements in standing on two legs with the eyes open and closed were measured with the Mac Reflex motion analysis system (Qualisys AB, Partille, Sweden) and calculated as maximal anterior-posterior and total movements. The associations between movement values and age and sex were analysed. During standing on two legs with the eyes open, there was a statistically significant difference in the maximal anterior-posterior head movement between the age groups (P < 0.05) but the results did not show any other statistically significant differences between the balancing movements of the separate body parts of the groups or between the balance measurement values of men and women in standing on two legs with the eyes open and closed. In standing on two legs with the eyes closed all the measured body parts moved more than in standing with the eyes open (P < 0.001). It was concluded that healthy men and women seem to control their steady standing position with quite similar ranges of body adjustment. Standing balance control should also possibly be evaluated and trained in more difficult circumstances, because some changes do not necessarily appear in easier balance tasks or performance.

Endplate degeneration observed on magnetic resonance imaging of the lumbar spine: correlation with pain provocation and disc changes observed on computed tomography diskography.

STUDY DESIGN: One hundred and three lumbar intervertebral discs (L3/4-L5/S1) of 36 patients with low back pain were examined with computed tomography (CT) diskography and magnetic resonance imaging (MRI). OBJECTIVES: To determine whether lumbar endplate degeneration correlates with the degree of disc degeneration or disc rupture and to determine if there is an association between pain provocation during diskography and lumbar endplate degeneration. SUMMARY OF BACKGROUND DATA: There have been numerous attempts to explain the pathogenesis of pain provocation during diskography, but the possibility of endplate degeneration as a source of pain has not been widely assessed. METHODS: One hundred and three lumbar intervertebral discs (36 L3/4, 36 L4/5, and 31 L5/S1 intervertebral discs) of 36 patients were examined. On the basis of MRI, the intervertebral discs were divided into four categories based on the degree of endplate degeneration. Based on pain provocation on diskography, the intervertebral discs were divided into three categories: no pain, indifferent/untypical pain, and familiar/typical pain. Based on disc degeneration and disc rupture, the intervertebral discs were divided into four categories in accordance with the Dallas Discogram Description: Grades 0-3 of both degeneration and rupture. RESULTS: There was a positive correlation between endplate degeneration and disc degeneration and a positive correlation between disc rupture and pain provocation, but there was no association between endplate degeneration and disc rupture and no correlation between endplate degeneration and pain provocation on diskography. CONCLUSIONS: This study showed a stronger association between endplate degeneration and disc degeneration than between endplate degeneration and disc rupture. The results indicate that the contrast injection during diskography reflects mainly pain of discogenic origin, whereas the possible pain associated with endplate damage cannot be depicted by CT diskography.

MRI changes of cervical spine in asymptomatic and symptomatic young adults.

Several work-related, psychosocial and individual factors have been verified as being related to neck and shoulder pain, but the role of pathology visualized by magnetic resonance imaging (MRI) remains unclear. In this study, the relationship between neck and shoulder pain and cervical high-field MRI findings was investigated in a sample of persons in a longitudinal survey. The study aimed to determine whether subjects with persistent or recurrent neck and shoulder pain were more likely to have abnormal MRI findings of cervical spine than those without neck and shoulder pain. A random sample of 826 high-school students was investigated initially when the students were 17-19 years, and again when they had reached 24-26 years of age. Eighty-seven percent participated in the first survey in 1989, of whom 76% took part in the second survey, in 1996. The validated Nordic Musculoskeletal Questionnaire was used to collect data about neck and shoulder symptoms. Two groups were chosen for the MRI study: the first group ( n=15) consisted of the participants who had reported no neck and shoulder symptoms in either of the inquiries, while the second group ( n=16) comprised those who were suffering from neck and shoulder symptoms once a week or more often at the time of both surveys. The degrees of disc degeneration, anular tear, disc herniation and protrusion were assessed by two radiologists. The differences between the two study groups were evaluated. The study found that abnormal MRI findings were common in both study groups. Disc herniation was the only MRI finding that was significantly associated with neck pain. These findings indicate that pathophysiological changes of cervical spine verified on MRI seem to explain only part of the occurrence of neck and shoulder pain in young adults.

Gadolinium diethylenetriaminepentaacetic acid enhancement in magnetic resonance imaging in relation to symptoms and signs among sciatic patients: a cross-sectional study.

STUDY DESIGN: A cross-sectional descriptive study. OBJECTIVES: Gadolinium enhancement in lumbar magnetic resonance imaging is not used routinely. The current study explored the possible intercorrelations of enhancement patterns with clinical symptoms and signs. SUMMARY OF BACKGROUND DATA: Rim enhancement has been reported to occur in the periphery of disc herniations, and it is thought to represent neovascularization. To the authors' knowledge, the significance of the enhancement in relation to clinical symptoms has not been studied. METHODS: Magnetic resonance imaging of the lumbar spine with intravenous gadolinium diethylenetriaminepentaacetic acid was performed in each patient. Various contrast enhancement parameters and volume of herniation were evaluated, and their correlations with clinical signs and symptoms (straight leg raising, motor defect, Achilles reflex, leg and back pain, disability) were analyzed. RESULTS: The extent of rim enhancement correlated highly significantly with the degree of disc displacement, being most pronounced in the case of sequesters. The duration of sciatic symptoms correlated negatively with enhancement. The clinical symptoms did not correlate significantly with the different enhancement parameters or disc herniation volume. Straight leg raising correlated only slightly with the extent of rim enhancement (P = 0.04) when bulges were excluded. Achilles reflex abnormality correlated significantly with all enhancement parameters for lesions at L5-S1. In the final stepwise logistic regression model, contrast enhancement extent correlated most significantly with abnormal Achilles reflex (P = 0.0002). CONCLUSIONS: Although rim enhancement of disc herniation is thought to represent a beneficial phagocytotic phenomenon, it may also have a harmful effect on the adjacent nerve root.

Associations between pain, grip strength, and manual tests in the treatment evaluation of chronic tennis elbow.

OBJECTIVE: The objective was to assess the associations between changes in pain and grip strength and manual tests among patients with chronic tennis elbow. DESIGN: Measurements for 45 consecutive patients with unilateral tennis elbow were made before and after an exercise intervention. SETTING: The setting was a physiatric outpatient clinic. PATIENTS: The patients were 45 persons with chronic unilateral tennis elbow: 32 women and 13 men. The mean age was 44 (31-54) years; mean duration of symptoms was 35 (10-66) weeks. OUTCOME MEASURES: Manual tests, pressure pain thresholds at three cubital points, a pain questionnaire, a pain drawing, and grip strength measurements were assessed. RESULTS: Grip strength became normal during the treatment. Pressure pain thresholds reached 66% of that of the healthy arm. Lowered pain thresholds and changes in pain thresholds of the lateral epicondyle were strongly associated with the findings in the manual tests. Mills test and resisted wrist extension tests were associated with perceived pain, and resisted wrist extension tests also were associated with decreased grip strength. Pain on palpation was associated with lowered pain thresholds at the lateral epicondylus and with perceived pain under physical load. After the treatment, for 13 patients all 4 manual tests were still positive; for 17 patients, 3 were still positive; and for 5 patients, all were negative. Positive clinical tests were associated with lowered pain thresholds, decreased grip strength, and high perceived pain scores. CONCLUSIONS: Pain thresholds at the lateral epicondyles are strongly associated with pain on palpation and with a positive Mills test. Resisted wrist extension test results reflect decreased grip strength. Impaired function of the hand is associated with the number of positive clinical tests. Pain threshold evaluation is a simple, easy, inexpensive method that provides useful additional quantitative data on pain and disability among patients with chronic tennis elbow.