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Mesotherapy versus Systemic Therapy in the Treatment of Acute Low Back Pain: A Randomized Trial

Cosimo Costantino,1,* Emilio Marangio,2 and Gabriella Coruzzi3

1Department of Surgical Sciences, Section of Orthopedy, Traumatology and Functional Rehabilitation, University of Parma, 43121 Parma, Italy

2Department of Clinic Sciences, Section of Respiratory Physiopathology, University of Parma, 43121 Parma, Italy

3Department of Human Anatomy, Pharmacology and Forensic Medicine, University of Parma, 43121 Parma, Italy

*Cosimo Costantino: Email: [email protected]

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Received April 9, 2010; Revised June 24, 2010; Accepted August 7, 2010.

Copyright © 2011 Cosimo Costantino et al.

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC.

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Abstract

Pharmacological therapy of back pain with analgesics and anti-inflammatory drugs is frequently associated with adverse effects, particularly in the elderly. Aim of this study was to compare mesotherapic versus conventional systemic administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids in patients with acute low back pain. Eighty-four patients were randomized to receive anti-inflammatory therapy according to the following protocols: (a) mesotherapy group received the 1st and 4th day 2% lidocaine (1 mL) + ketoprofen 160 mg (1 mL) + methylprednisolone 40 mg (1 mL), then on 7th, 10th, and 13th day, 2% lidocaine (1 mL) + ketoprofen 160 mg (1 mL) + methylprednisolone 20 mg (1 mL) (b) conventional therapy group received ketoprofen 80 mg × 2/die and esomeprazole 20 mg/die orally for 12 days, methylprednisolone 40mg/die intramuscularly for 4 days, followed by methylprednisolone 20 mg/die for 3 days, and thereafter, methylprednisolone 20 mg/die at alternate days. Pain intensity and functional disability were assessed at baseline (T0), at the end of treatment (T1), and 6 months thereafter (T2) by using visual analogic scale (VAS) and Roland-Morris disability questionnaire (RMDQ). In both groups, VAS and RMDQ values were significantly reduced at the end of drug treatment and after 6 months, in comparison with baseline. No significant differences were found between the two groups. This suggests that mesotherapy may be a valid alternative to conventional therapy in the treatment of acute low back pain with corticosteroids and NSAIDs.

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1. Introduction

Low back pain affects a high proportion of adult population in the developed countries and has a major impact on health care system and society [1, 2]. Conventional pharmacological therapy to reduce pain, inflammation, and functional disability usually relies upon the extensive use of nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), corticosteroids, and various opioids. However, the major drawback of pharmacological therapy with analgesics and anti-inflammatory drugs is the frequent association with adverse effects [3]; in particular, NSAID-related toxicity is connected to the inhibition of constitutive prostaglandins (PGs), with consequent impairment of gastric mucosal defense and renal homeostasis [4]. On the other hand, the availability of selective cyclooxygenase-2 (COX-2) inhibitors (Coxibs), despite providing a reduction in the gastrointestinal toxicity, resulted in a high risk of developing serious cardiovascular and renal side effects [5, 6]. Chronic therapy with systemic corticosteroids may afford a variety of serious untoward reactions, leading to hypertension, diabetes, glaucoma, gastric ulcer, osteoporosis, and psychiatric disorders [7, 8]. Finally, opioids, used either alone or in combination with paracetamol and/or NSAIDs, may cause a variety of side effects which are dose-limiting and reduce quality of life, bowel dysfunction being one of the most common and persisting problems [9]. Thus, new therapeutic options endowed with comparable efficacy and better safety are warranted.

Among the various attempts to reduce drug toxicity, the use of local therapy (neural block, intraarticular, or periarticular injections of corticosteroids) has gained popularity among physicians [10, 11], despite some controversies concerning its efficacy as a therapeutic remedy [12].

During the last decades, researchers and patients have become increasingly interested in complementary and alternative medicine (CAM) as a possible mean to ensure efficacy, while improving therapeutic safety [13–15]. Back pain, in particular, is the most common reason for CAM use both in Europe and USA [15]. However, despite the large favour by the general population and several published clinical studies, only few physical treatments are supported by strong scientific evidence [16–18]; likewise, controlled clinical studies evaluating the effectiveness of the most popular CAM therapies used for low back pain are still scarce [19], very few mechanistic studies are available [20, 21], the quality of research is generally poor, and general conclusions are difficult to reach [16].

Mesotherapy was introduced 50 years ago by Michel Pistor, a French physician who utilized this technique as a novel analgesic therapy for a variety of rheumatologic disorders [22]. Mesotherapy is a minimally invasive technique that consists of subcutaneous injections of drugs and, occasionally, plant extracts, homeopathic agents, or other bioactive substances; for this reason, it has been often considered a CAM, rather than a conventional medical therapy [23, 24]. Since its introduction, the use of mesotherapy has been expanded, and therapeutic indications have increased; although most applications are found in osteoarticular pathologies [25–28], over the recent years, this technique has become popular in cosmetic medicine for the treatment of cellulite and fat deposition [29, 30].

Based on these premises, the following study was designed to evaluate the effectiveness of anti-inflammatory drugs (NSAIDs and corticosteroids) administered via mesotherapy in comparison with conventional systemic therapy by oral and intramuscular route, for the treatment of acute low back pain.

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2. Methods

The study was carried out at the Department of Physical Medicine and Rehabilitation of the University of Parma following the guidelines for experimental investigation with human subjects required by the local University. Informed written consent was obtained from each patient.

2.1. Patient Recruitment

Patients were recruited for the study from the Emergency Department between January and May 2007 and checked for eligibility by the clinical investigator. Patients were enrolled into the study, provided that they had been suffering from back pain since no more than 2 weeks and reported a current pain intensity >65 on a 100 mm visual analogic scale (VAS). Exclusion criteria were represented by diabetes, anticoagulant therapy, or pregnancy. Patients were also excluded if they had evidence of cardiovascular, renal, hepatic, gastrointestinal, or psychiatric diseases. Eighty-four patients (44 men, 40 women) aged 24–77 years and suffering from acute low back pain, with cruralgia or sciatalgia were included into the study. Patients could leave the study at any time for any reason.

2.2. Study Design

Patients who met the eligibility criteria were randomly allocated to receive anti-inflammatory therapy with NSAIDs (ketoprofen) and corticosteroids (methylprednisolone, MP), administered either by mesotherapic technique or by oral/intramuscular route, according to the study plan described in Figure 1.

Figure 1

Study design and drug treatment.

Drug regimen employed in group A (22 men, 20 women) was as follows: 2% lidocaine (1 mL) + ketoprofen 160 mg (1 mL) + MP 40 mg (1 mL) at day 1 and 4, then 2% lidocaine (1 mL) + ketoprofen 160 mg (1 mL) + MP 20 mg (1 mL) at day 7, 10, and 13. Five repeated injections (3 mL for each injection) were administered at inter and paravertebral level along the running of sciatic nerve, through specific needles (30 G × 4 mm), which were inserted deeply for the whole lenght (Figure 2). Lidocaine was used to minimize pain at site of injection.

Figure 2

Injection points of a single mesotherapic treatment. Drug injections were administered along the running of sciatic nerve, through specific needles (30 G × 4 mm) (see Methods, for details).

Group B (22 men, 20 women) received drug therapy according to the following protocol: ketoprofen 80 mg X2/die orally for 12 days; MP intramuscularly 40 mg/die for the first 4 days, then 20 mg/die for 3 days, then 20 mg/die at alternate days. Patients of this group received esomeprazole 20 mg/die for 12 days, as gastroprotective therapy.

2.3. Outcome Measures

Self-rated pain intensity was assessed by using the VAS scale (0 = no pain, 100 intolerable pain), a horizontal, unmarked 100 mm scale widely validated to assess pain [31]. Functional disability in the daily life activity was measured by the Roland-Morris disability questionnaire (RMDQ) (varying score from 0 to 24). Both parameters were evaluated at baseline (T0), at the end of the drug treatment (12 days, T1), and at 6 months thereafter (follow up, T2) by two independent observers blind to the pharmacological treatment.

2.4. Statistical Analysis

All quantitative data were entered into a specifically designed database (SPSS V 17.01). Chi-Square Mann-Whitney and Kolmogorov-Smirnov test were employed to evaluate the omogeneity of the groups, as for sex or age, respectively. Wilcoxon signed rank test was utilized to analyze the variations among values obtained at baseline (T0), end of treatment (T1), followup (T2), and T0-T1, T1-T2; Krusall-Wallis test was used to analyze differences among T0-T1-T2. F test was employed for variance analysis and T test for independent data. A P value < .05 was considered statistically significant.

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3. Results

3.1. Patient Characteristics

A total of 84 patients were enrolled into the study. All treated groups were balanced with respect to demographic and baseline characteristics (Table 1). In particular, the patient distribution between the groups was comparable as for sex and age, scores for pain (VAS), and functional disability (RMDQ).

Table 1

Baseline characteristics of patients.

3.2. Pain and Functional Disability

In group A (mesotherapy), VAS and RMDQ scores were significantly reduced at the end of the pharmacological treatment (P < .0001) whereas after 6 months only VAS score was still significantly different from baseline (P = .04) (Figure 3). In group B (conventional pharmacotherapy), VAS and RMDQ were significantly reduced at the end of the treatment (P < .0001 and P < .001, resp.) and both scores were still significantly different from baseline after 6 months (P = .673 and P = .400, resp., versus data at the end of drug administration) (Figure 4). Mesotherapy was well-tolerated and local or allergic reactions were not observed. Minimal pain during and after injection was prevented by the local anaesthetic. Transient bleeding and signs of inflammation occurred in patients at the site of injection, but they resolved in a few days.

Figure 3

Effect of anti-inflammatory drugs on the reduction of pain, as measured by visual analogic scale (VAS) in patients with acute low back pain. Drug treatment was done either via mesotherapy or via standard systemic route of administration (see methods ...

Figure 4

Effect of anti-inflammatory drugs on the reduction of functional disability, as measured by Roland-Morris disability questionnaire (RMDQ), in patients with acute low back pain. Drug treatment was done either via mesotherapy or via standard systemic route ...

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4. Discussion

The aim of this study was to evaluate the effectiveness of anti-inflammatory drugs administered via mesotherapy in patients with acute low back pain. Present results showed for the first time that the administration of NSAIDs and corticosteroids via mesotherapic technique can provide the same therapeutic benefit as that induced by conventional (oral and intramuscular) drug administration. Indeed, both treatments significantly reduced pain intensity and disability in daily life activity, and the effect was maintained up to 6 months. These results are in accordance with previous studies showing that naproxen and diclofenac, administered via mesotherapy, were more effective than after oral administration [27, 32, 33].

The major finding of this study is the comparable effectiveness of mesotherapy and conventional systemic therapy, despite the lower amount of drugs administered to patients undergoing mesotherapy (41,67% ketoprofen and 50% methylprednisolone) (Figure 5). The comparable efficacy of mesotherapy and conventional therapy, despite different drug dosages, is difficult to explain. Subcutaneous drug administration results in a very slow drug absorption in comparison with other systemic routes, such as oral and intramuscular; thus it could be hypothesized that anti-inflammatory drugs, administered via mesotherapy, achieve a high drug concentration into the subcutaneous tissue and exert local effects in close proximity to inflammatory cells, sensory fibers, and vascular mediators that orchestrate inflammation and pain.

Figure 5

Therapeutic outcome of mesotherapy in comparison with conventional systemic therapy for acute low back pain. These two routes of administration resulted in comparable efficacy, despite the lower (approximately 50%) total amount of drug administered via ...

Although no measurement was made in our study of drug plasma levels after the two routes of administration, it is presumable to hypothesize that mesotherapic treatment resulted in a lower systemic bioavailability of drugs, with consequent lower incidence of adverse reactions. This could offer a great therapeutic advantage, when considering the high rates of adverse effects, associated with NSAID or corticosteroid use in the elderly population [3, 4, 7]. While the use of proton pump inhibitors has significantly limited the incidence of peptic ulceration and other acid-related disorders [34], renal and cardiovascular problems still remain of particular concern. In this connection, both nonselective and COX-2-selective NSAIDs were found to reduce glomerular filtration, increase fluid retention and blood pressure [5, 6], and some highly selective COX-2 inhibitors were found unfavourable in patients with cardiovascular diseases and were withdrawn from the market [5, 35]. Corticosteroids, on the other hand, may have a variety of side effects, including hypertension, diabetes, osteoporosis, glaucoma, and peptic ulcer, which are dose-dependent and related to the systemic drug availability [7, 8].

Although mesotherapic techniques used in dermatologic surgery have been associated with a number of adverse effects at sites of injection, including atypical mycobacterial infections [36], urticaria [37], lichenoid drug eruptions [38, 39], and psoriasis [40], no evidence of local reactions were found in the present study.

In conclusion, results of the study indicate that combined administration of conventional NSAIDs and corticosteroids by mesotherapy is an effective and well-tolerated method for managing low back pain in the short-term, compared with drug therapy administered by oral and intramuscular route. Possible weaknesses of our study are the small number of patients, the short followup period, and the lack of drug plasma level measurements. However, if confirmed in a large trial, these observations could be of potential interest in the pharmacological treatment of low back pain to reduce the adverse effects associated with high plasma levels of antiinflammatory drugs.

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Acknowledgments

The authors wish to thank Maurizio Agosti for helping in data analyses and Mrs. Sara Maxwell Scott for revising the language. This study was supported by a grant from the Dept Surgical Sciences Section of Orthopedy, Traumatology and Functional Rehabilitation, University of Parma. There was no financial assistance with the project. There is no potential conflict of interest existing with respect to the authors of this paper. The study gained the approval from the University of Parma Ethics Committee.

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Abstract

1. Introduction

2. Methods

3. Results

4. Discussion

Acknowledgments

References

J Phys Ther Sci. Dec 2013; 25(12): 1541–1545. Published online Jan 8, 2014. doi:  10.1589/jpts.25.1541PMCID: PMC3885835

The Effects of Stabilization and Mckenzie Exercises on Transverse Abdominis and Multifidus Muscle Thickness, Pain, and Disability: A Randomized Controlled Trial in NonSpecific Chronic Low Back PainMohammad Hosseinifar, PhD Candidate,1 Mohammad Akbari, PhD,1,* Hamid Behtash, MD,2 Mohsen Amiri, PhD,3 and Javad Sarrafzadeh, PhD1

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Abstract

[Purpose] This study compared the effectiveness of stabilization and McKenzie exercises on pain, disability, and thickness of the transverse abdominis and multifidus muscles in patients with nonspecific chronic low back pain. [Subjects] Thirty patients were randomly assigned into two groups: the McKenzie and stabilization exercise groups. [Methods] Before and after intervention, pain, disability, and thickness of the transverse abdominis and multifidus muscles were evaluated by visual analogue scale, functional rating index, and sonography, respectively. The training program was 18 scheduled sessions of individual training for both groups. [Results] After interventions, the pain score decreased in both groups. The disability score decreased only in the stabilization group. The thickness of the left multifidus was significantly increased during resting and contracting states in the stabilization group. The thickness of the right transverse abdominis during the abdominal draw-in maneuver, and thickness of the left transverse abdominis during the active straight leg raising maneuver were significantly increased in the stabilization group. The intensity of pain, disability score, thickness of the right transverse abdominis during the abdominal draw-in manouver, and thickness of the left transverse abdominis during active straight leg raising in the stabilization group were greater than those on the Mackenzie. [Conclusion] Stabilization exercises are more effective than McKenzie exercises in improving the intensity of pain and function score and in increasing the thickness of the transverse abdominis muscle.

Key words: Chronic low back pain, Stabilizaton exercises, Muscle thicknessGo to:

INTRODUCTION

Lack of spinal core stability is supposed to be one of the important predisposing causes of recurrent low back pain (LBP)1). As a result, more attention has been paid to training of localized spinal stabilizer muscles in subjects with LBP2). It is believed that specific

stabilization exercises lead to changes in motor programing of the automatic feed-forward recruitment of deep core muscles3). Therefore, stabilization exercises were suggested for chronic low back pain (CLBP) patients4,5,6,7).

Recently, it has been reported that the use of stabilization exercises can improve the multifidus (MF) muscle size in acute LBP2). However, few studies have reported the impacts of stabilization exercises on the size and function of stabilizer muscles8, 9). One study reported that the stabilization exercises led to an increase in the thickness of the stabilizer muscles8). Another study showed borderline changes in contracting thickness of the TrA muscle following application of stabilization exercises9). As a result, there is a lack of sufficient objective evidence about the effects of stabilization exercises on the thickness of the stabilizer muscles, especially thickness when contracted. Another approach is the McKenzie method10). This approach is focused on sustained postures or repeated movements11). Although McKenzie exercises could improve pain intensity in acute low back pain, subacute low back pain and CLBP12), no study with regard to the effect of McKenzie exercises on the thickness of the stabilizer muscles in CLBP was found in a review of the literature.

As mentioned above, this study was carried out to determine and compare the effectiveness of stabilization and McKenzie exercises on pain, disability and TrA and MF muscle thickness in resting and contracting states in patients with nonspecific CLBP. It was hypothesized that stabilization exercises would increase the thickness of TrA and MF muscles and that McKenzie exercises would not have any effects on the thickening of the TrA and MF muscles.

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SUBJECTS AND METHODS

In this single randomized controlled trial study, the participants were selected through a simple non-probability sampling method and were randomly divided into two equal groups using sequences of random numbers. The first group (n=15) performed stabilization exercises, and the second group (n=15) performed McKenzie exercises. The examiner who assessed the outcomes was blinded to group assignment. The training program consisted of 18 sessions of supervised individual training for both groups, with the sessions performed 3 times per week for 6 weeks. Each training session lasted an hour and was performed at the Physiotherapy Clinic in the School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran, between 2011 and 2012. Outcomes were measured in both groups before and after treatments. The study protocol was approved by the ethics committee of Tehran University of Medical Sciences. All patients provided written informed consent to participate in the study.

Thirty patients with nonspecific CLBP participated in this study on the basis of a clinical examination performed by a physician and the following inclusion criteria: age between 18–50 years, CLBP in the area between the costal margin and buttocks, with or without reference to the lower extremity (no radicular pain) that lasted more than 3 months. Patients were excluded if they had a history of recent fracture, trauma or previous surgery in the lumbar region; had spondylolysis or spondylolisthesis, spinal stenosis, neurological disorders, systemic diseases, cardiovascular diseases, diseases; were pregnant; were receiving

concomitant treatment, with physical therapy modalities; or were receiving other therapies simultaneously7, 13).

After referral by a specialist, patients were reviewed based on the inclusion and exclusion criteria. Then demographic characteristics including age, sex, height, and weight were collected using a questionnaire. The pain history including the onset, location, and duration was recorded. Prior to and following the intervention, we measured pain, disability, and TrA and MF muscle thickness at rest and during contraction by visual analogue scale (VAS), Functional Rating Index (FRI) questionnaire, and ultrasound imaging, respectively.

The VAS was used for pain assessment13). In this scale, pain was rated from 0 to 100 mm, in which the 0 represented no pain and 100 represented maximum pain tolerance. Subjects were asked to mark the best number indicating their pain. The data were then recorded in the questionnaire12).

Disability was evaluated through the Persian version of the FRI questionnaire. The questionnaire served as a tool specifically designed for quantifying mental comprehension of function and spinal pain in the clinical conditions. The reliability and validity of the questionnaire have already been demonstrated in previous studies14). The questionnaire has 10 sections, and each section was rated using the same 5-point scale. Patients scored their existing disability by choosing one of the grades (the grades ranged from 0 to 4, grade 0 meant without pain and able to complete the respective function, and grade 4 meant the maximum pain and inability to perform the functions). The overall score was calculated by the sum of the scores of all sections and was expressed by a percentage between 0 (no disability) and 100 (severe disability).

Ultrasound imaging is a reliable and reproducible method for evaluation of muscle structure, function, and activity15). This method allows assessment of muscle activity by measuring changes in muscle geometry during contraction16). In this study, there was high intra-tester reliability for the ultrasound measurements of the MF and TrA muscle thicknesses at rest and during contraction (ICCs= 0.87 to 0.96). To measure the thicknesses of the MF and TrA muscles, a B-mode ultrasound apparatus (MyLab 50 XVision, ESAOTE S.p.A, Genova Italy) was used. Measurement of the thicknesses of the TrA and MF muscles was performed in a resting position and during the tasks with submaximal muscle contraction on both sides17). To record the thicknesses of the TrA and MF muscles, we used an LA523 linear probe (set to 12 MHz) and a CA431 convex array probe (set to 7.5 MHz). In order to measure TrA muscle thickness, the subjects were set in crook-lying position18). The ultrasound probe was placed midway between the iliac crest and costal margin, on the midaxillary line, about 10 cm off the midline of body at the level of umbilicus19). TrA muscle thickness was measured in millimeters between the fascial lines, one centimeter away from the muscle junction in the direction of the thoracolumbar fascia18). The two submaximal tasks were performed for the TrA muscle, the abdominal draw-in maneuver (ADIM) and active straight leg raising (ASLR)20). MF muscle thickness measurements were performed in the prone position with a pillow under the abdomen. The probe was placed along the spine, such that the midpoint of the probe was in line with the spinous process of the fourth lumbar vertebra. Then it was moved so that the facet joint between the fourth and fifth lumbar vertebrae was visible. This point is located directly on the MF muscle. The muscle thickness was measured from this point to the plane between the subcutaneous tissue and muscle16). The submaximal task for this muscle was elevation of the contralateral arm in a prone position with a small weight

(0.5 kg) on the arm, the elbow at a right angle, and the glenohumeral joint at 120 degrees of abduction21).

For warming up and before performing specific exercises, participants pedaled a stationary bike for 5 minutes and then did stretching exercises for 10 minutes13). Stabilization exercises were divided into 6 levels from easy to difficult. At the end of each training level, participants performed each exercise ten times for ten seconds with low intensity5, 13). During the treatment session, between 80 and 100 repetitions of the selected exercises were carried out in the McKenzie group22).

The stabilization exercises were performed in 6 steps: 1) Segmental Control Exercises (SCE) with emphasis on training the of isolated contraction of the TrA, MF, and pelvic floor muscles; 2) SCE with emphasis on co-contractions of the TrA, MF, and pelvic floor muscles in the prone, supine, and four-point kneeling positions; 3) closed kinematic chain SCE; 4) development of SCE into the low load apply by adding leverage of the limbs during open chain exercises; 5) development of SCE in functional situations; and 6) co-contraction of theTrA and MF muscles during application of an external load, complication of movements, increased load with the lumbar spine in the correct position, addition of a co-contraction pattern to light aerobic activities such as walking, and activities that have already exacerebated the symptoms4).

In the Mckenzie group, 6 exercises were used: four extension-type exercises and two flexion-type and two flexion-type exercises. The extension-type exercises were performed in prone and standing positions, and the flexion-type exercises were performed in the supine and sitting positions. The final position of each exercise was maintained for 10 seconds23).

The data were collected over 10 months and were analyzed using SPSS version 17. They were tested for a normal distribution using the Kolmogorov-Smirnov test. The independent samples t-test was used for comparing the Mckenzie and stabilization groups. The paired-t test was used to compare variables before and after training in each group. Statistical significance for all tests was accepted below the 0.05 level.

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RESULTS

Demographic variables had a normal distribution. No significant difference was observed between the demographic characteristics of the two groups. The patients’ demographic characteristics are listed in Table 1. The study design and the corresponding flow diagram are shown in Fig. 1. The following data were not distributed normally after treatment: resting thickness of the left TrA, thickness of the left TrA during ADIM in the stabilization group, and resting thickness of the right TrA in the McKenzie group.

Table 1.

Between-group baseline comparison of subjects’ characteristics

Fig. 1.Flow diagram outlining progress throughout the trial

Pain decreased in both the Mckenzie and stabilization groups after the intervention (p <0.05). The disability score decreased only in the stabilization group (p <0.05). The mean thickness of the left MF muscle when contracted, resting thickness of the left TrA muscle, thickness of the right TrA muscle during ADIM, and thickness of the left TrA during ASLR increased in the stabilization group (p <0.05) (Table 2).

Table 2.Means and standard deviations of variables within and between group comparison

Comparison of pain, function, and thickness of the TrA and MF muscles before treatment showed no difference between two groups (p>0.05). The changs in the pain and disability scores and right TrA muscle thickness during ADIM and the thickness of the left TrA muscle during ASLR were greater than those in the stabilization group (p <0.05). Other variables showed no significant difference between the two groups (p> 0.05) (Table 2).

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DISCUSSION

The results of this study showed that pain decreased following application of stabilization and Mckenzie exercises. Disability decreased only after the application of stabilization exercises. The results indicated that the effect of stabilization exercises on pain and disability was greater than Mckenzie exercises in CLBP. Also, stabilization exercises were effective in increasing the resting thickness of the left TrA muscle, the thickness of the right TrA muscle during ADIM, the thickness of the left TrA muscle during active SLR, thickness of the left MF muscle when contracted. Comparison of the effects between the two methods of exercises on muscle thickness showed that stabilization exercises were more effective than Mckenzie exercises in increasing the thickness of the right TrA muscle during ADIM, and the thickness of left TrA muscle during ASLR.

Despite the borderline changes that occurred in the thickness of the TrA muscle when contracted in Vasseljen and Fladmark’s study9), in the present study, the thicknesses of the TrA and MF muscles when contracted increased in some of the outcomes. In our study, the

exercise types were different from those used in Vasseljen and Fladmark’s study. The results of this study regarding the changes in resting thickness of the TrA muscles following application of stabilization exercises were consistent with the study by Akbari et al8). They showed an increase in resting thickness of the TrA and MF muscles following the application of stabilization exercises8). In the present study, the resting thickness of the left TrA increased.

Accordingly, depending on the purpose of exercise applications, effects of exercises on the muscles can lead to hypertrophy or neuromuscular adaptation9). With the emphasis placed on low-level contraction and isolation of the TrA muscles during stabilization exercises, it is expected that most of the effects of stabilization exercises are related to neuromuscular adaptation9). However, muscle hypertrophy typically occurs after 8 to 12 weeks of intensive strengthening exercises2, 24). Thus, we proposed that the short duration of the present study and effects of neuromuscular adaptation led to changes in some of the outcomes.

The findings of this study are consistent with the findings of previous studies in terms of improvement in pain and function following the application of stabilization exercises4, 6, 8, 13,

25,26,27,28,29). Also, stabilization exercises were found to be superior to McKenzie exercises in our study, as shown by the decreases in pain and disability, which is consistent with the results of other studies7, 29). Although stabilization exercises are the most important methods in rehabilitation of LBP disorders and in prophylaxis, the exact biological basis for the efficacy of stabilization exercises in LBP patients is not clear yet30). Several mechanisms have been proposed to describe the effects of stabilization exercises on pain26). These mechanisms include reduction of load and improvement in the quality of movements following improvement in co-ordination of trunk muscles31). In addition, the stabilization exercises targeted the main deep muscle affected by LBP29, 32). As a result, deep muscle stabilizer muscles could influence by stabilization exercises in LBP patients32). Therefore, a change in muscle thickness was only seen after stabilization exercises.

Considering the above mentioned points, pain reduction in the Mckenzie group might have occurred due to other causes without changes in the thickness of abdominal and MF muscles. This approach was focused on sustained postures or repeated movements, and pain reduction migth have been due to postural correction11).

Therefore, both types of exercises reduced pain in patients with nonspecific CLBP. Disability was reduced only in stabilization group. Also, stabilization exercises were effective in increasing the resting thickness of theleft TrA muscle, thickness of the right TrA muscle during ADIM, thickness of the left TrA muscle during ASLR, and thickness of the left MF muscle when contracted. Stabilization exercises were more effective than Mckenzie exercises in reducing pain and disability, increasing the right TrA muscle thickness during ADIM, and increasing the left TrA muscle thickness during ASLR.

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Acknowledgments

The study was funded and supported by Tehran University of Medical Sciences (Grant No: P/26/d4/738).

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REFERENCES

1. George SZ, Childs JD, Teyhen DS, et al. : Rationale, design and potocol for the prevention of low back pain in the military (POLM) trial. BMC Musculoskelet Disord, 2007, 8: 92 [PMC free article] [PubMed]2. Danneels LA, Cools AM, Vanderstraeten GG, et al. : The effects of three different training modalities on the cross-sectional area of the paravertebral muscles. Scand J Med Sci Sports, 2001, 11: 335–341 [PubMed]3. Millisdotter M, Strömqvist B.: Early neuromuscular customized training after surgery for lumbar disc herniation: a prospective controlled study. Eur Spine J, 2007, 16: 19–26 [PMC free article] [PubMed]4. O’Sullivan PB, Twomey LT, Allison GA.: Evaluation of specific stabilization exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine, 1997, 22: 2959–2967 [PubMed]5. Sung PS.: Multifidi muscles median frequency before and after spinal stabilization exercise. Arch Phys Med Rehabil, 2003, 84: 1313–1318 [PubMed]6. Luomajoki H, Kool J, Bruin ED, et al. : Improvement in low back movement control, decreased pain and disability, resulting from specific exercise intervention. Sports Med Arthrosc Rehabil Ther Tecnol, 2010, 2: 11 [PMC free article] [PubMed]7. Goldby LJ, Moore AP, Doust J, et al. : A randomized controlled trial investigating the efficiency of musculoskeletal physiotherapy on chronic low back disorder. Spine, 2006, 31: 1083–1093 [PubMed]8. Akbari A, Khorashadizadeh S, Abdi G.: The effect of motor control exercise versus general exercise on lumbar local stabilizing muscles thickness: randomized controlled trial of patients with chronic low back pain. Back Musculoskelet Rehabil, 2008, 21: 105–1129. Vasseljen O, Fladmark AM.: Abdominal muscle contraction thickness and function after specific and general exercises: a randomised controlled trial in chronic low back pain patients. Man Ther, 2010, 15: 482–489 [PubMed]10. McCarthy CJ, Arnall FA, Strimpakos N, et al. : The biopsychosocial classification of non-specific low back pain: a systematic review. Phys Ther Rev, 2004, 9: 17–30 11. Petersen T, Larsen K, Jacobsen S.: One-year follow-up comparison of the effectiveness of McKenzie treatment and strengthening training for patients with chronic low back pain: outcome and prognostic factors. Spine, 2007, 32: 2948–2956 [PubMed]12. Skikić EM, Suad T.: The effects of McKenzie exercise for patients with low back pain, our experience. Bosn J Basic Med Sci, 2003, 3: 70–75 [PubMed]13. Koumantakis GA, Watson PJ, Oldham JA.: Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Phys Ther, 2005, 85: 209–225 [PubMed]14. Ansari NN, Feise RJ, Naghdi S, et al. : The functional rating index: reliability and validity of the persian language version in patients with low back pain. Spine (Phila Pa 1976), 2011, 36: E1573-E1577. [PubMed]15. Rasouli O, Arab AM, Amiri M, et al. : Ultrasound measurement of deep abdominal muscle activity in sitting positions with different stability levels in subjects with and without chronic low back pain. Man Ther, 2011, 16: 388–393 [PubMed]16. Kiesel KB, Uhl T, Underwoodc FB, et al. : Rehabilitative ultrasound measurement of select trunk muscle activation during induced pain. Man Ther, 2008, 13: 132–138 [PubMed]

17. Teyhen DS, Miltenberger CE, Deiters HM, et al. : The use of ultrasound imaging of the abdominal drawing-in maneuver in subjects with low back pain. J Orthop Sports Phys Ther, 2005, 35: 346–355 [PubMed]18. Saliba SA, Croy T, Guthrie R, et al. : Differences in transverse abdominis activation with stable and unstable bridging exercise in individuals with low back pain. N Am J Sports Phys Ther, 2010, 5: 63 [PMC free article] [PubMed]19. Costa LO, Maher CG, Latimer J, et al. : An investigation of the reproducibility of ultrasound measures of abdominal muscle activation in patients with chronic non-specific low back pain. Eur Spine J, 2009, 18: 1059–1065 [PMC free article] [PubMed]20. Kiesel KB, Uhl TL, Underwood FB, et al. : Measurement of lumbar multifidus muscle contraction with rehabilitative ultrasound imaging. Man Ther, 2007, 12: 161–166 [PubMed]21. Hebert JJ, Koppenhaver SL, Magel JS, et al. : The relationship of transversus abdominis and lumbar multifidus activation and prognostic factors for clinical success with a stabilization exercise program: a cross-sectional study. Arch Phys Med Rehabil, 2010, 91: 78–85 [PubMed]22. Twomey LT, Taylor JR.: Physical Therapy of the Low Back. New York: Churchill Livingstone, 1994, pp 171–196.23. Kinkade S.: Evaluation and treatment of acute low back pain. Am Fam Physician, 2007, 75: 1181–1188 [PubMed]24. Enoka RM.: Neural adaptations with chronic physical activity. J Biomech, 1997, 30: 447–455 [PubMed]25. Cairns MC, Foster NE, Wright C.: Randomized controlled trial of specific spinal stabilization exercise and conventional physiotherapy for recurrent low back pain. Spine, 2006, 31: E670–E681 [PubMed]26. Costa LO, Maher CG, Latimer J, et al. : Motor control exercise for chronic low back pain: a randomized placebo-controled trial. Phys Ther, 2009, 89: 1275–1286 [PubMed]27. Muthukrishnan R, Shenoy S, Jaspal SS, et al. : The differential effects of core stabilization exercise regime and conventional physiotherapy regime on postural control parameters during perturbation in patients with movement and control impairment chronic low back pain. Sport Med Arthrosc Rehabil Ther Technol, 2010, 2: 13 [PMC free article] [PubMed]28. Ferreira ML, Ferreira PH, Latimer J, et al. : Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: a randomized trial. Pain, 2007, 131: 31–37 [PubMed]29. França FR, Burke TN, Hanada ES, et al. : Segmental stabilization and muscular strengthening in chronic low back pain − a comparative study. Clinics, 2010, 65: 1013–1017 [PMC free article] [PubMed]30. Hodges P.: Transversus abdominis: a different view of the elephant. Br J Sports Med, 2008, 42: 941–944 [PubMed]31. Hodges PW, Moseley GL.: Pain and motor control of the lumbopelvic region: effect and possible mechanisms. J Electromyogr Kinesiol, 2003, 13: 361–370 [PubMed]32. Hodges P.: Lumbo-Pelvic Stability: A Functional Model of the Biomechanics and Motor Control. In: Therapeutic Exercise for lumbopelvic Stabilization; A Motor Control Approach for the Treatment and Prevention of Low Back Pain. Edinburgh: Churchill Livingstone, 2004, pp 13–14.

Subdeltoideus Bursitis Manifested as Gigantic Cystic Supraclavicular and Lateralcervical TumourA. Demetrian,1 R. Melinte,2 I. Mândrilă,1 and Rodica Dilof1

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Abstract

The authors present a case of a left gigantic supraclavicular and lateralcervical tumor with rapid growth, which has turned out to be a subdeltoideus bursitis.

Keywords: subdeltoideus bursitis, cystic tumour, supraclavicular, synovial liquidGo to:

Case Report

We present the case of a 79 years old patient, who was admitted to the hospital for the emergence within a relatively short interval (approximately two weeks) of a right supraclavicular pseudotumoral formation of large dimensions (12/10 cm), in the absence of any notion of trauma, intense effort, insect bite, surgical intervention or local diagnosing procedure (puncture).

The formation presents characters of liquid fluctuation, without signs of local inflammation, discretely painful at feeling and with minimum signs of compression at the level of the brachial plexus (pain and moderate parestesis at the level of the upper right limb).

The movements in the right scapularhumeral joint, although possible and painless, proved to be limited by the volume of the formation.

The thorax examination highlighted a minimum diminishing of the vesicular murmur in the upper third of the right hemithorax, without clinical signs of pleuresis of the large right cavity.

During the commitment period, the formation’s increase in volume continued, with a right lateralcervical evolution, maintaining the fluctuant character at feeling.

The cervical-thoracic computer-tomographic examination indicated the presence of a formation with cystic aspect, oval-like, well bordered, of 7.6/6.4 cm, situated supraclavicular right, located medial of the trapezius muscle, lateral of the scapula lifting muscle and the medial and posterior scalene muscles; the carotid artery and the jugular vein without visible modifications (fig. (fig.11).

Fig.1Computer-tomograph images of the case

The imagistic data and the clinical aspect suggested the existence of a subdeltoideus bursitis.

We performed the formation draining puncture through a posterior percutaneus aboard, with the draining of 400 ml serous citrin liquid and the subsequent total disappearance of the regional deformation.

The cytologic examination of the liquid extracted indicated an inflammatory aspect with rare cellular elements (lymphocytes, polymorphonuclear leucocytes, cropped out nuclei, red blood corpuscles and cellular detritus).

The evolution was favorable, with the total disappearance of the cystic formation and of the minimum symptomatology described previously.

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Anatomy

The shoulder is not constituted solely of the glenohumeral joint, but from several joints that make up the shoulder’s articular system. The number of joints is different, the authors including in this articular complex 7 (Cailliet R., 1984), 5 (Kapandji I. A., 1966) or 3 (Bonnel F., 1988) joints [1].

The variety of the complex movements performed in these joints is possible also due to the existence of the periarticular muscles and of the perihumeral synovial bursae.

The vast space occupied by the synovial cavities within the shoulder’s articular system raises the issue of the role of the synovia in the biomechanics of this system, the synovia behaving as a intermuscular liquid cushion with role in modulating the movements of the shoulder and arm [2].

By means of a minute dissection in the deltopectoral space, with the clavicular desinsertion of the deltoid muscle and the removal towards the side of the obtained flap, it is possible to visualize the prominences of the upper humerus extremity: the small tuberculum and the large tuberculum, separated by a depression well visible due to the transparency of the conjunctive structures.

In the intertubercular space there is identified the tendon of the long biceps portion, with its synovial bursa homologated as "vagina synovialis intertubercularis". It is a synovial covering considered as an extension of the sinovia of the glenohumeral joint which accompanies the bicipital tendon for 4-5 cm in the intertubercular channel.

Lateral and superior of the prominence determined by the large tuberculum of the humerus, it is located the synovial subdeltoideus bursa, which presents as a sliding space between the acromiocoracoid arch and the deltoid muscle. After the opening of this bursa, the space under the acromiocoracoid arch can be easily explored [3].

In a profound foreground there is the conjunctive acromiocoracoid arch underneath which it is possible to enter the subacromial bursa interposed between the acromial arch and the acromiocoracoidian ligament. After the sectioning of this ligament in a sagittal plan, one can visualize the posterior extension of the subacromiocoracoid space.

The scapularthoracic joint, also described by Gill and named by Latarjet "scapularthoracic junction" [4], is a physiological joint which has two sliding spaces: the omodentatus space and the parietodentatus space. These spaces are occupied by sinovial bursae: a superficial bursa, inconstant, present between the inferior angle of the scapula and the latissimus dorsi muscle; the scapulartrapezoidal bursa, between the superior angle of the scapula and the trapezius muscle; two deep bursae, the scapularthoracic bursa bordered by the anterior dentatus muscle and the thoracic wall and the subscapular bursa between the anterior dentatus and the subscapular muscles [5].

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Discussion

The scapularthoracic bursitis can cause important pain and the limiting of movements in the scapular-humeral joint. The diagnosis is often one of exclusion, many times being made after a long period in which the symptoms persist or aggravate [6].

In our case, this interval was relatively short due to the impressive volume and the rapid growth pace which determined the patient to come to the physician.

The affection can be idiopathic (the case presented) or due to an abnormal mechanics between the scapula and the secondary ribs’ grid, to a bone focal lesion (elastofibroma, osteocondroma) or to the altered morphology of the thoracic wall posttraumatic or postsurgery [7].

Sometimes, the existence of a bursitis can cause crepitations during movements.

The diagnostic arsenal comprises the ecohgraphy, the computer-tomography and the nuclear magnetic resonance.

The medical treatment consists of non steroid anti-inflammatories and cyclooxygenase inhibitors. Sometimes, the local application of ice or heat can be benefic. Some rheumatologists practice locale injections with corticoids inside the bursa.

In our patient, we considered the liquid draining procedure more adequate than the treatment described above for two reasons: the total absence of the pain syndrome and the impressive dimension of the formation.

In case of relapse (important re-accumulation of liquid), we would have been forced to resort to the arthroscopic removal of the bursa walls.

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References

1. Bonnel F., Blotman F., Mansat M., editors. L`epaule . L`epaule degenerative, l`epaule traumatique, l`epaule du sportif. Diagnostique – Reeducation – Chirurgie – Arthroscopie. Paris; Berlin : Springer; 1993. pp. 3–65.2. Melinte Rodica, Dragoi G.S., Melinte P. Razvan, Dogaru C. Raluca. A new Concept for describing the movements in the glenohumeral joint. Acta of Bioengineering and Biomechanics; The 13th European Conference of Biomechanics; 2002 September 2-4 ; Wroclaw, Poland. 2002. pp. 626–627. The 13th European Conference of Biomechanics, September 2-4, 2002, Wroclaw, Poland.3. Drăgoi S.G., Rodica Melinte, Mândrilă I., Mihaela Niculescu, Melinte V. R. Contribuţii la studiul evaluarii handicapului şi prejudiciilor aduse structurilor sistemului articular al umărului. Implicaţii în expertiza clinică medico-legală Revista Română de Medicină Legală 1999;7(3):216–232.4. Testut L., Latarjet A. Traite d'Anatomie humaine. 8. 1928. 1928. huithieme edition, revue corrigee et augmentee par Latarjet.5. Williams G.R., Shakil M., Klimkiewicz J., Iannotti J.P. Anatomy of the scapulothoracic articulation. Clin Orthop Relat Res. 1999 Feb;359:237–246. [PubMed]6. Saboeiro G. R., Carolyn M. Sofka. Imaging-Guided Treatment of Scapulothoracic Bursitis. HSS J. 2007 Sep;3(2):215–undefined. [PMC free article] [PubMed]7. Fujikawa A, Oshika Y, Tamura T, Naoi Y. Chronic scapulothoracic bursitis associated with thoracoplasty. AJR Am J Roentgenol. 2004;183(5):1488–undefined. [PubMed]