Omer Matthijs

Differential Diagnosis and Management of Spinal Nerve Root-related Pain

Abstract: Pain originating from spinal nerve roots demonstrates multiple pathogeneses. Distinctions in the patho‐anatomy, biomechanics, and pathophysiology of spinal nerve roots contribute to pathology, diagnosis, and management of root‐related pain. Root‐related pain can emerge from the tension events in the dura mater and nerve tissue associated with primary disc related disorders. Conversely, secondary disc‐related degeneration can produce compression on the nerve roots. This compression can result in chemical and mechanical consequences imposed on the nervous tissue within the spinal canal, lateral recess, intervertebral foramina, and extraforminal regions. Differences in root‐related pathology can be observed between lumbar, thoracic, and cervical spinal levels, meriting the implementation of different diagnostic tools and management strategies.

Pain Generators of the Lumbar Spine

Abstract Different anatomical structures and pathophysiological functions can be responsible for lumbar pain, each producing a distinctive clinical profile. Pain can arise from the intervertebral disc, either acutely as a primary disc related disorder, or as result of the degradation associated with chronic internal disc disruption. In either case, greatest pain provocation will be associated with movements and functions in the sagittal plane. Lumbar pain can also arise from afflictions within the zygapophyseal joint mechanism, as result of synovitis or chondropathy. Either of these conditions will produce the greatest pain provocation during three‐dimensional movements, due to maximal stress to either the synovium or joint cartilage. Finally, patients can experience different symptoms associated with irritation to the dural sleeve, dorsal root ganglion, or chemically irritated lumbar nerve root. Differential diagnosis of these conditions requires a thorough examination and provides information that can assist the clinician in selecting appropriate management strategies.

Diagnosis and Management of the Painful Ankle/Foot Part 1: Clinical Anatomy and Pathomechanics

Abstract:  Distinctive anatomical features can be witnessed in the ankle/foot complex, affording specific pathological conditions. Disorders of the ankle/foot complex are multifactoral and features in both the clinical anatomy and biomechanics contribute to the development of ankle/foot pain. The superior tibiofibular, distal tibiofibular, talocrural, subtalar, and midtarsal joint systems must all participate in function of the ankle/foot complex, as each biomechanically contributes to functional movements and clinical disorders witnessed in the lower extremity. A clinicians ability to effectively evaluate, diagnose, and treat the distal lower extremity is largely reliant upon a foundational understanding of the clinical anatomy and biomechanics of this complex complex. Thus, clinicians are encouraged to consider these distinctions when examining and diagnosing disorders of the ankle/foot.

Interrater Reliability of Palpation of Three-Dimensional Segmental Motion of the Lumbar Spine

Abstract The purpose of this study was to evaluate interrater reliability of a specific palpatory test to assess the three-dimensional (3-D) mobility of L4-L5. Subjects included 17 men and 37 women with a mean age of 24 years (range 20-39 years) who were tested independently by three manual physical therapists with a mean of 15 years of experience. Testers performed 3-D motion testing of the L4-L5 spinal segment in a non-weight-bearing position. Interrater reliability was assessed with Cohens Kappa statistics, using three pair-wise comparisons for determination of the direction (right or left) of lateral flexion leading to the greatest amount of segmental rotation. Percent agreement ranges were 46.3% to 62.9%, with Kappa scores ranging from −0.16 to 0.04, respectively. The palpatory test demonstrated poor to slight strength of interrater reliability. Further examination of a symptomatic population and/or other age categories is recommended. This study suggests that quantitative manual palpatory assessment of rotation at L4-L5 in combination with ipsilateral or contralateral lateral flexion is not reliable between testers. Such testing is not recommended for clinical use.

Assessment of Lumbar Spine Height Following Sustained Lumbar Extension Posture: Comparison Between Musculoskeletal Ultrasonography and Stadiometry

OBJECTIVES The purpose of this study was to correlate sitting height measured by stadiometry with lumbar spine height (LSH) modifications measured by musculoskeletal ultrasonography (MSU). METHODS Eighteen healthy young adults were recruited for this study (mean age: 21.5 ± 1.5 years). All subjects were tested in the following sequence: (1) lying supine for 10 minutes, (2) sitting under loaded (9.5 kg) and unloaded conditions for 5 minutes each, (3) lying supine for 15 minutes with passive lumbar extension, and (4) sitting unloaded for 5 minutes. Both stadiometry and MSU measurements were taken after each step of the testing sequence. RESULTS Following the loaded sitting step, sitting height (measured by stadiometry) decreased by 3.4 ± 1.6 mm, whereas following sustained lumbar extension, sitting height increased by 5.4 ± 3.5 mm (P < .05). Following loaded sitting and sustained lumbar extension, LSH decreased by 3.8 ± 1.7 mm and increased by 6.2 ± 4.1 mm, respectively (P < .05). On the basis of the mean differences (between the different steps of the testing sequence), the mean correlation coefficient and the mean coefficient of determination between stadiometry and MSU measurements were calculated at 0.93 ± 0.07 and 0.88 ± 0.13, respectively, and no statistical differences were observed (P > .05). CONCLUSIONS In vivo measurements of sitting height changes, measured using stadiometry, were strongly correlated with LSH changes, measured using ultrasonography.

Reliability and validation of in vitro lumbar spine height measurements using musculoskeletal ultrasound: A preliminary investigation

BACKGROUND Stadiometry measures total trunk height variations but cannot quantify individual spinal segment height changes. Different methods exist to measure both intervertebral disc and lumbar spine height (LSH) variations but they are either limited by radiation exposure or cost. Musculoskeletal ultrasound could be a valuable alternative to measure spinal segmental height changes as a result of intervention. OBJECTIVE To validate the use of musculoskeletal ultrasound (MSU) and new anatomical landmark references used in assessing inter-mammillary distances (IMD) and LSH changes resulting from lumbar spine traction. METHODS Two unembalmed cadaveric lumbar spines were extracted to assess (1) the reliability and validity of MSU, as compared to caliper, for measuring in vitro IMD and LSH using alternative anatomical landmarks than previously reported, and (2) the reliability of MSU for measuring in vitro IMD and lumbar spine height changes recorded during standardized mechanical traction up to 1.20 cm. RESULTS Intra- and inter-rater reliability of musculoskeletal ultrasound for within and between sessions and for all experimental design, Standard Error ranged from 0.01 to 0.02 and from 0.03 to 0.04 cm for IMDs and LSHs, respectively. Root Mean Square Errors ranged from 1.6 to 6.8% and from 1 to 1.1% for IMDs and LSHs, respectively and mean ICC ranged from 0.98 to 1 for LSH. During traction, mean lumbar spine height measurement change using MSU was 1.15 ± 0.03 cm. Bland and Altman plots demonstrated confidence intervals included in the limits of agreement. Nevertheless, there were significant differences (p< 0.001) for both IMD measurements and lumbar spine height between caliper and ultrasound measurements. Musculoskeletal ultrasound overestimated distances of about 5.5 ± 1.5%. CONCLUSIONS Musculoskeletal ultrasound is reliable and accurate for measuring intersegmental spinal distances and lumbar spine height with an apparent slight overestimation of distances. Based on mean differences, ultrasound technology seems to be valid for measuring lumbar spine height changes and could be suitable for in vivo research.