The Effect of Bipolar Pulsed Radiofrequency Treatment on Chronic Lumbosacral Radicular Pain Refractory to Monopolar Pulsed Radiofrequency Treatment.

BACKGROUND: Patients with lumbosacral radicular pain may complain of persisting pain after monopolar pulsed radiofrequency (PRF) treatment. OBJECTIVE: We evaluated the effect of bipolar PRF stimulation of the dorsal root ganglion (DRG) in patients with chronic lumbosacral radicular pain who were unresponsive to both monopolar PRF stimulation of the DRG and transforaminal epidural steroid injection (TFESI). STUDY DESIGN: This is a prospective observational study. SETTING: The outpatient clinic of a single academic medical center in Korea. METHODS: We retrospectively reviewed data from 102 patients who had received monopolar PRF to the DRG for management of lumbosacral radiculopathy. Of these, 32 patients had persistent radicular pain that was scored at least 5 on a numeric rating scale (NRS). Twenty-three of them were included in this study and underwent bipolar PRF of the DRG. The outcomes after the procedure were evaluated using the NRS for radicular pain before treatment and 1, 2, and 3 months after treatment. Successful pain relief was defined as >/= 50% reduction in the NRS score compared with the score prior to treatment. Furthermore, at 3 months after treatment, patient satisfaction levels were examined. Patients reporting very good (score = 7) or good results (score = 6) were considered to be satisfied with the procedure. RESULTS: The NRS scores changed significantly over time. At 1, 2, and 3 months after bipolar PRF, the NRS scores were significantly reduced compared with the scores before the treatment. Twelve (52.2%) of the 23 patients reported successful pain relief and were satisfied with treatment results 3 months after bipolar PRF. No serious adverse effects were recorded. LIMITATIONS: A small number of patients were recruited and we did not perform long-term follow-up. CONCLUSION: We believe the use of bipolar PRF of the DRG can be an effective and safe interventional technique for chronic refractory lumbosacral radiculopathy. It appears to be a potential option that can be tried before proceeding to spinal surgery. KEY WORDS: Bipolar, pulsed radiofrequency, lumbosacral radicular pain, chronic pain, dorsal root ganglion, spinal stenosis, herniated disc.

Comparison of Intra-articular Thoracic Facet Joint Steroid Injection and Thoracic Medial Branch Block for the Management of Thoracic Facet Joint Pain.

STUDY DESIGN: A prospective observational study. OBJECTIVE: The aim of this study was to show the effect of intra-articular (IA) thoracic facet joint (TFJ) steroid injection for the management of TFJ pain, and to compare it with the effect of therapeutic thoracic medial branch block (MBB) with a local anesthetic and steroid. SUMMARY OF BACKGROUND DATA: Several studies have shown the effects of thoracic MBB with local anesthetics with or without steroids and radiofrequency neurotomy in managing TFJ pain, but thus far, the effectiveness of IA TFJ steroid injection has not been studied. METHODS: Forty patients with TFJ pain were recruited and randomly assigned to one of two groups, the IA steroid injection and the MBB group, each with 20 patients. For IA TFJ steroid injection and therapeutic MBB, we injected 0.5 mL of 0.5% bupivacaine, mixed with 10 mg (0.25 mL) of dexamethasone. We assessed the severity of TFJ pain using a numeric rating scale (NRS) before treatment and at 1, 3, and 6 months after treatment. RESULTS: Compared to the pretreatment NRS scores, the NRS scores at 1, 3, and 6 months after each treatment showed a significant decrease in patients in both the groups. Intergroup changes in the NRS scores were not significantly different over time. Six months after the treatment, 65% of the patients in the IA steroid injection group reported successful pain relief (pain relief ≥50%), and 40% of the patients in the MBB group showed successful pain relief. CONCLUSION: In the present study, both IA TFJ steroid injection and therapeutic MBB significantly relieved TFJ pain. Their effects persisted for at least 6 months after the procedure. Thus, we think that both IA TFJ steroid injection and therapeutic thoracic MBB are useful treatment options for managing TFJ pain. LEVEL OF EVIDENCE: 2.

Transcutaneous neuromuscular electrical stimulation applied to optimal points on the lower abdomen and lumbar paraspinal region changes gait parameters in patients with lumbar degenerative kyphosis.

BACKGROUND: Lumbar degenerative kyphosis (LDK) is characterized by sagittal imbalance resulting from degenerative loss of lumbar lordosis. The ability of transcutaneous neuromuscular electrical stimulation (NMES) to activate deep lumbar stabilizing muscles has been demonstrated. OBJECTIVE: The aim of this study was to evaluate the effects of transcutaneous NMES applied to optimal points on the lower abdomen and lumbar paraspinal region on gait problems in patients with lumbar degenerative kyphosis (LDK). METHODS: Twenty-one patients with lumbar degenerative kyphosis underwent three walking sessions in the following order; walking for 5 minutes without NMES, walking with NMES on the lumbar multifidus (LM) only, and walking with NMES on both LM and transverse abdominis (TrA)/obliquus internus (OI). Differences in gait parameters at the commencement and completion of each of the three sessions were evaluated by gait analysis. RESULTS: During the 5-minute walk with NMES applied to the LM or to the LM and TrA/OI, participants showed lesser increases in spine forward tilt, pelvic anterior tilt, and external foot progression angle, and a lesser decrease in hip internal rotation than when walking without NMES (P< 0.05). In addition, with NMES, patients showed less decrement in gait velocity and stride length at walk completion than patients walking without NMES (P< 0.05). However, in the comparison between walks with NMES applied to the LM and walks with NMES applied to the LM and TrA/OI, we could not find any significant difference in changes of gait parameters (p> 0.05). CONCLUSIONS: Transcutaneous NMES applied at optimal points on the lower abdomen and back could provide a means of treating gait problems caused by a stooped trunk in LDK patients.

The effect of intra-articular stimulation by pulsed radiofrequency on chronic sacroiliac joint pain refractory to intra-articular corticosteroid injection: A retrospective study.

We investigated the degree of pain reduction following intra-articular (IA) pulsed radiofrequency (PRF) stimulation of the sacroiliac joint (SIJ) in patients with chronic SIJ pain that had not responded to IA corticosteroid injection. Twenty patients were recruited. Clinical outcomes after applying PRF stimulation of the SIJ were evaluated by a numeric rating scale (NRS) and a 7-point Likert scale. The NRS scores significantly changed over time. The NRS scores at 1, 2, and 3 months after PRF were significantly lower than those before PRF. However, 4 of the 20 patients (20%) reported successful pain relief (pain relief of ≥ 50%) and were satisfied with the PRF stimulation at 3 months after treatment. IA PRF stimulation of the SIJ was not successful in most patients (80% of all patients). Based on our results, we cannot recommend this procedure to patients with chronic SIJ pain that was unresponsive to IA SIJ corticosteroid injection. Further studies on the effective mode of PRF stimulation and appropriate patient group, and studies on pain conditions that are most responsive to PRF are needed in the future.

Diffusion Tensor Tractography for Detection of Concomitant Traumatic Brain Injury in Patients With Traumatic Spinal Cord Injury.

OBJECTIVES: We investigated concomitant traumatic brain injury in patients with traumatic spinal cord injury (TSCI) who had head trauma history, using diffusion tensor tractography (DTT). DESIGN: Retrospective survey. PARTICIPANTS: We recruited 14 consecutive patients with TSCI and coexisting head trauma history at the time of TSCI and 30 control subjects. METHODS: The corticospinal tract (CST), corticoreticulospinal tract (CRT), cingulum, and fornix were reconstructed using DTT, and DTT parameters (fractional anisotropy and fiber volume) and configuration were estimated. RESULTS: The values of fractional anisotropy and fiber volume in the CST, CRT, cingulum, and fornix of the patient group were significantly lower than those of the control group (P < .05). On configurational analysis of DTT for each tract, the neural tracts for motor function (the CST and CRT) had more injury than the neural tracts for cognitive function (the cingulum and fornix). No association between the severity of TSCI and traumatic brain injury was observed in terms of DTT parameters. CONCLUSIONS: Using DTT, we found injury of the neural tracts in patients with head trauma history at the time of TSCI. Our results suggest that brain evaluation using DTT can be recommended for the patients with head trauma history at the time of TSCI irrespective of the results of conventional brain MRI.

Comparison between bipolar pulsed radiofrequency and monopolar pulsed radiofrequency in chronic lumbosacral radicular pain: A randomized controlled trial.

BACKGROUND: Chronic lumbosacral radicular pain is a challenging medical problem with respect to therapeutic management. Many patients with lumbosacral radicular pain complain of persistent leg pain after transforaminal epidural steroid injection. Nowadays, pulsed radiofrequency (PRF) stimulation on the dorsal root ganglion (DRG) is widely used for controlling lumbosacral radicular pain. METHODS: We evaluated the effect of bipolar PRF on the DRG for the management of lumbosacral radicular pain. In addition, we compared the effect of bipolar PRF to monopolar PRF. Fifty patients with chronic lumbosacral radicular pain were included in the study and randomly assigned to 1 of 2 groups, the bipolar or monopolar PRF group (n = 25 per group). Pain intensity was evaluated using a numeric rating scale (NRS) at pretreatment, and 1, 2, and 3 months after treatment. RESULTS: When compared to the pretreatment NRS scores, patients in both groups showed a significant decrease in NRS scores at 1, 2, and 3 months after treatment. Reductions in the NRS scores over time were significantly larger in the bipolar PRF group. Three months after treatment, 19 patients (76.0%) in the bipolar PRF group and 12 patients (48.0%) in the monopolar PRF group reported successful pain relief (pain relief of ≥50%). CONCLUSION: The use of bipolar PRF on the DRG can be an effective and safe interventional technique for chronic refractory lumbosacral radiculopathy, particularly in patients whose pain are refractory to epidural steroid injection or monopolar PRF stimulation.

Comparison of intra-articular lumbar facet joint pulsed radiofrequency and intra-articular lumbar facet joint corticosteroid injection for management of lumbar facet joint pain: A randomized controlled trial.

BACKGROUND: This study aimed to demonstrate the effect of intra-articular (IA) lumbar facet joint (LFJ) pulsed radiofrequency (PRF) for the management of LFJ pain, and to compare the effect of IA LFJ PRF to IA corticosteroid injection (ICI). Pathology in the LFJ is a common source of lower back pain (LBP). It is responsible for chronic LBP in approximately 15% to 45% of patients. It has been reported that PRF stimulation can effectively reduce refractory joint pain. METHODS: Sixty patients with LFJ pain were recruited and randomly assigned to 1 of 2 groups: the IA PRF group and the ICI group. There were 30 patients in each group. At pretreatment, 2 weeks, 1, 3, and 6 months after treatment, we assessed the severity of LBP using a numeric rating scale (NRS). RESULTS: Compared with the pretreatment NRS scores, patients in both groups showed a significant decrease in NRS scores at 2 weeks, and 1, 3, and 6 months after each treatment. Between groups, changes in the NRS scores were significantly different over time. At 2 weeks and 1 month after each procedure, the NRS score after ICI was significantly lower than that after the PRF stimulation. However, at 3 and 6 months after the procedures, the decrements of NRS scores were not significantly different between the 2 groups. Six months after treatment, about half of patients in both groups reported successful pain relief (pain relief of ≥50%). CONCLUSION: In the current study, both IA PRF stimulation and ICI into the LFJ significantly relieved LFJ pain. Their effects persisted for at least 6 months after the procedure. Thus, IA PRF is a useful therapeutic option for the management of LFJ pain.

Changes in Neuroglial Activity in Multiple Spinal Segments after Caudal Epidural Pulsed Radiofrequency in a Rat Model of Lumbar Disc Herniation.

BACKGROUND: Herniated lumbar discs can induce sciatica by mechanical compression and/or chemical irritation. It was recently reported that neuroglial cellular activity after pulsed radiofrequency (PRF) application to a single dorsal root ganglion (DRG) attenuated neuroglial activity at the corresponding spinal dorsal horn. Recently, caudal epidural PRF has been used to manage neuropathic pain, but evidence of molecular changes after the administration of caudal epidural PRF to attenuate neuropathic pain is lacking, and it has not been determined whether caudal epidural PRF affects neuroglial activity at different spinal levels. OBJECTIVES: Using immunohistochemical methods in a rat model of lumbar disc herniation, the authors investigated the effects of caudal epidural PRF administration on pain-related behavior, on the activations of microglia and astrocytes in spinal cord, and on the expressions of calcitonin gene-related peptide (CGRP) and Transient receptor potential vanilloid 1(TRPV1) in the DRG at the L3, L4, L5, L6, and S1 levels. STUDY DESIGN: Controlled animal trial. SETTING: University hospital laboratory. METHODS: Forty-five Sprague-Dawley rats were randomly assigned to a sham-operated group (n = 10) or a nucleus pulposus (NP)-exposed group (n = 35). Rats in the NP-exposed group were further subdivided into a NP-exposed with sham stimulation group (the NP-nonPRF group; n = 13) or a NP exposed with caudal epidural PRF stimulation group (the NP-PRF group; n = 22). Pulsed radiofrequency was administered on postoperative day 10 (POD 10) by placing an electrode in the caudal epidural space through the sacral hiatus and administering 5 Hz of PRF current for 600 seconds (maximum tip temperature 42°C). Rats were tested for mechanical allodynia on POD 10 and on days 7 and 14 after caudal epidural PRF administration (post-PRF). At 14 days post-PRF, sections of the spinal cord from L3, L4, L5, L6, and S1 were immunostained for ionized calcium-binding adapter molecule 1 (Iba1) and glial fibrillary acidic protein (GFAP), and DRGs from the same levels were immunostained for CGRP and TRPV1. RESULTS: Mechanical withdrawal thresholds increased at 7 days post-PRF (P = 0.04), and the immunohistochemical expression of Iba1 in the L5 spinal dorsal horn and of CGRP in the L5 DRG were quantitatively reduced (P < 0.001) at 14 days post-PRF. Furthermore, the upregulations of Iba1 at L3, L4, L6, and S1 dorsal horns and CGRP at L6 DRG were also attenuated by caudal epidural PRF (P < 0.001). LIMITATION: We examined molecular changes only in ipsilateral lumbar regions and at 14 days post-PRF. CONCLUSION: Caudal epidural PRF reduced mechanical allodynia and downregulated microglia activity and CGRP expression at the lumbar disc herniated level and in adjacent lumbar spinal levels in a rat model of lumbar disc herniation.Key words: Caudal, pulsed radiofrequency, multisegmental, lumbar disc herniation, microglia, calcitonin gene-related peptide.

Comparison of the Effects of Ultrasound-Guided Interfascial Pulsed Radiofrequency and Ultrasound-Guided Interfascial Injection on Myofascial Pain Syndrome of the Gastrocnemius.

OBJECTIVE: To investigate the comparative treatment effects of ultrasound-guided pulsed radiofrequency treatment (UG-PRF) in the gastrocnemius interfascial space and ultrasound-guided interfascial injection (UG-INJ) on myofascial pain syndrome. METHODS: Forty consecutive patients with myofascial pain syndrome of the gastrocnemius were enrolled and were allocated to one of the two groups. Twenty patients were treated by UG-PRF delivered to the gastrocnemius interfascial space (UG-PRF group) and the other 20 patients were treated by interfascial injection (UG-INJ group). The primary outcome measure was the numeric rating score (NRS) for pain on pressing the tender point in the gastrocnemius, and the secondary outcome measure was health-related quality of life as determined by the Short Form-36 questionnaire (SF-36). NRSs were obtained at the first visit, immediately after treatment, and at 2 and 4 weeks post-treatment, and physical component summary scores (PCS) and mental component summary scores (MCS) of the SF-36 questionnaire were measured at the first visit and at 4 weeks post-treatment. RESULTS: Immediately after treatments, mean NRS in the UG-PRF group was significantly higher than that in the UG-INJ group (p<0.0001). However, at 2 and 4 weeks post-treatment, the mean NRS was significantly lower in the UG-PRF group (both p<0.0001). Similarly, at 4 weeks post-treatment, mean PCS and MCS were significantly higher in the UG-PRF group (p<0.0001 and p=0.002, respectively). CONCLUSION: Based on these results, the authors conclude that ultrasound-guided gastrocnemius interfascial PRF provides an attractive treatment for myofascial pain syndrome of the gastrocnemius.

A New Sacroiliac Joint Injection Technique and Its Short-Term Effect on Chronic Sacroiliac Region Pain.

OBJECTIVES: Sacroiliac joint (SIJ) injections have been used to provide short-term relief of SIJ pain. In this study, the authors investigated a new technique using a superior approach. METHODS: Twenty four patients with chronic SI joint paint were recruited. Each patient was treated with a single SIJ intra-articular injection plus a periarticular injection of local anesthetic and corticosteroid in one procedure. Technical accuracy of the intra-articular procedure was determined by having 2 independent observers review and rate the quality of arthrograms obtained. Treatment effects were evaluated using a numerical rating scale, the Oswestry disability index (ODI) and global perceived effect (GPE). RESULTS: Both independent observers agreed that satisfactory arthrograms were obtained in all patients. Pain scores and disability were significantly reduced at 2 weeks and 4 weeks after treatment. Nineteen patients (79%) reported satisfaction with treatment. No serious adverse effects were encountered. CONCLUSIONS: The superior approach consistently achieves good access to the SI joint, and achieves outcomes that are compatible with those of other techniques. The superior approach constitutes an alternative to other techniques for injections into the SI joint.

Comparative Effectivenesses of Pulsed Radiofrequency and Transforaminal Steroid Injection for Radicular Pain due to Disc Herniation: a Prospective Randomized Trial.

Transforaminal Epidural steroid injections (TFESI) have been widely adopted to alleviate and control radicular pain in accord with current guidelines. However, sometimes repeated steroid injections have adverse effects, and thus, this prospective randomized trial was undertaken to compare the effectivenesses of pulsed radiofrequency (PRF) administered to a targeted dorsal root ganglion (DRG) and TFESI for the treatment of radicular pain due to disc herniation. Subjects were recruited when first proved unsuccessful (defined as a score of > 4 on a visual analogue scale (VAS; 0-10 mm) and of > 30% according to the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI)). Forty-four patients that met the inclusion criteria were enrolled. The 38 subjects were randomly assigned to receive either PRF (PRF group; n = 19) or additional TFESI (TFESI group; n = 19) and were then followed for 2, 4, 8, and 12 weeks. To evaluate pain intensity were assessed by VAS. ODI and NDI were applied to evaluate functional disability. Mean VAS scores for cervical and lumbar radicular pain were significantly lower 12 weeks after treatment in both study groups. NDI and ODI scores also declined after treatment. However, no statistically significant difference was observed between the PRF and TFESI groups in terms of VAS, ODI, or NDI scores at any time during follow-up. PRF administered to a DRG might be as effective as TFESI in terms of attenuating radicular pain caused by disc herniation, and its use would avoid the adverse effects of steroid.

Raster-stereographic evaluation of the effects of biomechanical foot orthoses in patients with scoliosis.

[Purpose] Little is known about the effects of biomechanical foot orthoses in scoliosis, as determined by raster stereography. The objective of this study was to investigate the effect of individually manufactured biomechanical foot orthoses on scoliosis angle, trunk imbalance, and pelvic obliquity by comparing them with general insoles by using DIERS formetric 4 dimensional in patients with scoliosis. [Subjects and Methods] Twenty-six patients with scoliosis were recruited at Yeungnam University Hospital and allocated equally to one of two groups, the biomechanical foot orthoses group or the control group. Parameters, such as, trunk rotation, imbalance, and scoliosis angle, were obtained using a DIERS formetric 4D. [Results] Scoliosis angle, pelvic obliquity, and trunk imbalance were significantly different between the two groups and improved in the biomechanical foot orthoses group with time, but no significant improvement in any parameter was observed in the control group. [Conclusion] Biomechanical foot orthoses could be effective in patients with scoliosis, and DIERS formetric 4D provides a useful method for evaluating scoliosis parameters.

Two-Year Outcome of Percutaneous Bipolar Radiofrequency Neurotomy of Sacral Nerves S2 and S3 in Spinal Cord Injured Patients with Neurogenic Detrusor Overactivity: A Randomized Controlled Feasibility Study.

BACKGROUND: Little research has been expended on the use of bipolar radiofrequency (RF) lesioning of sacral nerves in spinal cord injured (SCI) patients with neurogenic detrusor overactivity (NDO), and no study has been undertaken to demonstrate its long-term effect. OBJECTIVE: To investigated the effect of bipolar RF ablation of the second and third sacral nerves over 2 years in SCI patients with NDO. STUDY DESIGN: A prospective, randomized controlled feasibility study. SETTING: The outpatient clinic of a single academic medical center in Korea. METHODS: Ten SCI patients with NDO were recruited. These patients were randomly assigned to 2 groups; the intervention group (n = 5) and the control group (n = 5). Control group members received optimized conventional treatment. International Consultation on Incontinence Questionnaire (ICIQ), 3-day voiding diary, and the urinary incontinence quality of life scale (I-QOL) data were obtained at baseline and at 6, 12, and 24 months after intervention. Urodynamic study (UDS) was performed at baseline and 24 months after intervention. In the intervention group, percutaneous bipolar RF neurotomy was performed on both S2 and S3 nerves in each patient. RESULTS: Frequency of urinary incontinence and ICIQ and IQOL scores showed significant effects for time and for the group x time interaction (P < 0.05). Daily mean volume of urinary incontinence showed only a significant group effect. In UDS parameters, comparisons of values at baseline and at 24 months revealed all variables showed significant intergroup differences (P < 0.05). LIMITATION: A small number of patients was recruited. CONCLUSION: Percutaneous bipolar RF ablation of sacral nerves S2 and S3 effectively reduces urinary incontinence and improves quality of life (QoL) in SCI patients with NDO and the effects lasted over 2 years.

Changes in deep lumbar stabilizing muscle thickness by transcutaneous neuromuscular electrical stimulation in patients with low back pain.

BACKGROUND: Transcutaneous neuromuscular electrical stimulation (NMES) is known to stimulate contraction of deep lumbar stabilizing muscles. OBJECTIVE: The purpose of this study was to investigate changes in deep lumbar stabilizing muscle thickness during transcutaneous NMES on specific abdominal wall and paraspinal regions. METHODS: Thirty patients with low back pain (LBP) were recruited. Three sessions were preformed: Session 1: NMES on abdominal wall, Session 2: NMES on lumbar paraspinal area, and Session 3: concurrent NMES on abdominal wall and lumbar paraspinal area. Real time ultrasound imaging (RUSI) of three abdominal stabilizing muscles; transverse abdominis (TrA), obliquus internus (OI), obliquus externus (OE) muscles and one posterior stabilizer, the lumbar multifidus muscles (LM) was captured. RESULTS: All studied muscles of TrA, OI, OE, and LM were found to have significant thickness increases during all three sessions compared to resting state (p < 0.05). Thicknesses changes of TrA, OI, and LM were significant during simultaneous NMES of both abdominal wall and lumbar paraspinal regions (Session 3) (p < 0.05). CONCLUSIONS: Our results indicate that concurrent NMES on abdominal wall and lumbar paraspinal area is most effective to maximally activate deep lumbar stabilizers. Rehabilitative efforts for patients with LBP may benefit from simultaneous transcutaneous NMES of abdominal and lumbar regions.

The effects of biomechanical foot orthoses on the gait patterns of patients with malalignment syndrome as determined by three dimensional gait analysis.

[Purpose] The biomechanical effects of foot orthoses on malalignment syndrome have not been fully clarified. This experimental investigation was conducted to evaluate the effects of orthoses on the gait patterns of patients with malalignment syndrome. [Subjects and Methods] Ten patients with malalignment syndrome were recruited. For each participant, kinematic and kinetic data were collected under three test conditions: walking barefoot, walking with flat insoles in shoes, and walking with a biomechanical foot orthosis (BFO) in shoes. Gait patterns were analyzed using a motion analysis system. [Results] Spatiotemporal data showed the step and stride lengths when wearing shoes with flat insoles or BFO were significantly greater than when barefoot, and that the walking speed when wearing shoes with BFO was significantly faster than when walking barefoot or with shoes with flat insoles. Kinetic data, showed peak pelvic tilt and obliquity angle were significantly greater when wearing BFO in shoes than when barefoot, and that peak hip flexion/extension angle and peak knee flexion/extension and rotation angles were significantly greater when wearing BFO and flat insoles in shoes than when barefoot. [Conclusion] BFOs can correct pelvic asymmetry while walking.

The effects of transcutaneous neuromuscular electrical stimulation on the activation of deep lumbar stabilizing muscles of patients with lumbar degenerative kyphosis.

[Purpose] To investigate the effectiveness of three different neuromuscular electrical stimulation (NMES) protocols for the deep lumbar stabilizing muscles of patients with lumbar degenerative kyphosis (LDK). [Subjects and Methods] Twenty patients with LDK were recruited. Three stimulation protocols were investigated: stimulation of the abdominal muscles (protocol A); stimulation of the lumbar muscles (protocol B); and simultaneous stimulation of the abdominal and lumbar muscles (protocol A+B). Images of the obliquus externus (OE), obliquus internus (OI), transversus abdominis (TrA), and lumbar multifidus (LM) muscles were captured by real-time ultrasound imaging (RUSI). [Results] The thickness of LM was significantly greater during stimulation than at rest for all three protocols. Thicknesses of the abdominal muscles (TrA, OI, and OE) were significantly greater during stimulation than at rest for protocols A and A+B. Thickness increases in LM were significantly greater during protocols B and A+B, but not during protocol A. Thickness increases in the abdominal muscles (TrA, OI, and OE) were significantly greater during protocols A and A+B, but not during protocol B. [Conclusion] NMES can significantly activate the deep lumbar stabilizing muscles of patients with LDK. Protocol A+B of NMES is recommended to aid postural correction and low back pain (LBP) in patients with LDK.

The Effect of GCSB-5 a New Herbal Medicine on Changes in Pain Behavior and Neuroglial Activation in a Rat Model of Lumbar Disc Herniation.

OBJECTIVE: Lumbar disc herniation can induce sciatica by mechanical compression and/or chemical irritation. The aim of this study was to compare the effects of GCSB-5 (Shinbaro®) and NSAIDs on pain-related behavior and on the expressions of microglia, astrocytes, CGRP, TRPV1, IL-6, and CX3CL1 in a rat model of lumbar disc herniation. METHODS: 112 male Sprague-Dawley rats underwent implantation of nucleus pulposus to a dorsal root ganglion (DRG). Rats were divided into five groups as follows; a saline group (the vehicle control group) (n=27), a 10 mg/kg aceclofenac group (the aceclofenac group) (n=22), and 100, 300 or 600 mg/kg GCSB-5 groups (the GCSB-5 100, 300, or 600 groups) (n=21 for each group). Rats were tested for mechanical allodynia at 3 days after surgery and at 1 day, 3 days, 7 days, 14 days, 21 days, 28 days, 35 days, 42 days, 49 days, and 56 days after treatment commencement. Immunohistochemical staining of microglia (Iba1), astrocytes (GFAP), CGRP, and TRPV1, and PCR for IL-6 and CX3CL1 were performed on spinal dorsal horns and DRGs at 56 days after medication commencement. RESULTS: After 56 days of GCSB-5 300 administration, mechanical withdrawal thresholds were significantly increased (p<0.05), and immunohisto-chemical expressions of Iba1, GFAP, CGRP, and TRPV1 were reduced than other groups, but this difference was not statistically significant. CONCLUSION: These results indicate GCSB-5 reduces mechanical allodynia and downregulates neuroglial activity and the expressions of CGRP and TRPV1 in the spinal segments of a rat model of lumbar disc herniation.

Pelvic floor muscle contraction and abdominal hollowing during walking can selectively activate local trunk stabilizing muscles.

BACKGROUND: Trunk muscle exercises are widely performed, and many studies have been performed to examine their effects on low back pains. However, the effect of trunk muscles activations during walking with pelvic floor muscle contraction (PFMC) and abdominal hollowing (AH) has not been clarified. OBJECT: To investigate whether walking with PFMC and AH is more effective for promoting local trunk muscle activation than walking without PFMC and AH. METHODS: Twenty healthy men (28.9 ± 3.14 years, 177.2 ± 4.25 cm, 72.1 ± 6.39 kg, body mass index 22.78 ± 2.38 kg/m2) were participated in this study. Surface electrodes were attached over the multifidus (MF), lumbar erector spinae (LES), thoracic erector spinae (TES), transverse abdominus-internal oblique abdominals (TrA-IO), external oblique abdominals (EO), and rectus abdominus (RA). The amplitudes of electromyographic signals were measured during a normal walking with and without PFMC and AH. RESULT: PFMC and AH while walking was found to result in significant bilateral increases in the normalized maximum voluntary contraction (MVC) of MFs and TrA-IOs (p< 0.05). Ratios of local muscle activity to global muscle activities were increased while performing PFMC and AH during normal walking. Bilateral TrA-IO/EO activity ratios were significantly increased by PFMC and AH (p< 0.05). CONCLUSION: Performance of the PFMC and AH during walking resulted in significantly more recruitment of local trunk muscles. This study suggests that PFMC and AH during normal daily walking improves activation of muscles responsible for spinal dynamic stabilization and might be useful if integrated into low back disability and pain physical rehabilitation efforts.

ISSLS Prize Winner: Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis: Results of an International Delphi Study.

STUDY DESIGN: Delphi. OBJECTIVE: The aim of this study was to obtain an expert consensus on which history factors are most important in the clinical diagnosis of lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: LSS is a poorly defined clinical syndrome. Criteria for defining LSS are needed and should be informed by the experience of expert clinicians. METHODS: Phase 1 (Delphi Items): 20 members of the International Taskforce on the Diagnosis and Management of LSS confirmed a list of 14 history items. An online survey was developed that permits specialists to express the logical order in which they consider the items, and the level of certainty ascertained from the questions. Phase 2 (Delphi Study) Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 9 members of Taskforce where consensus was reached on a final list of 10 items. Round 3: Final survey was distributed internationally. Phase 3: Final Taskforce consensus meeting. RESULTS: A total of 279 clinicians from 29 different countries, with a mean of 19 (±SD: 12) years in practice participated. The six top items were "leg or buttock pain while walking," "flex forward to relieve symptoms," "feel relief when using a shopping cart or bicycle," "motor or sensory disturbance while walking," "normal and symmetric foot pulses," "lower extremity weakness," and "low back pain." Significant change in certainty ceased after six questions at 80% (P < .05). CONCLUSION: This is the first study to reach an international consensus on the clinical diagnosis of LSS, and suggests that within six questions clinicians are 80% certain of diagnosis. We propose a consensus-based set of "seven history items" that can act as a pragmatic criterion for defining LSS in both clinical and research settings, which in the long term may lead to more cost-effective treatment, improved health care utilization, and enhanced patient outcomes. LEVEL OF EVIDENCE: 2.

The effects of neuromuscular electrical stimulation at different frequencies on the activations of deep abdominal stabilizing muscles.

BACKGROUD: Low back pain is associated with transversus abdominis (TrA) dysfunction. Recently, it was proposed that Neuromuscular Electrical Stimulation (NMES) could be used to stimulate deep abdominal muscle contractions and improve lumbopelvic stability. OBJECTIVE: The purpose of this study was to determine the optimal stimulation frequency required during NMES for the activation of deep abdominal muscles. METHODS: Twenty healthy volunteers between the ages of 24 and 32 were included. The portable research-stimulator was applied using a 10 second contraction time, and a 10 second resting time at 20 Hz, 50 Hz, and 80 Hz. Changes in muscle thicknesses were determined for the TrA, obliquus internus (OI), and obliquus externus (OE) by real time ultrasound imaging. RESULTS: Significant thickness increases in the TrA, OI, and OE were observed during NMES versus the resting state (p < 0.05). Of the frequencies examined, 50 Hz NMES produced the greatest increase in TrA thickness (1.33 fold as compared with 1.22 fold at 20 Hz and 1.21 fold at 80 Hz) (p < 0.05). CONCLUSIONS: Our results indicate that NMES can preferentially stimulate contractions in deep abdominal stabilizing muscles. Most importantly, 50 Hz NMES produced greater muscle thickness increases than 20 or 80 Hz.