Teonette O. Velasco

Ultrasound Imaging: Intraexaminer and Interexaminer Reliability for Multifidus Muscle Thickness Assessment in Adults Aged 60 to 85 Years Versus Younger Adults

STUDY DESIGN Intraexaminer and interexaminer, within- and between-day reliability study. OBJECTIVES To compare the intraexaminer and interexaminer procedural reliability of ultrasound imaging (USI) thickness measurements of the lumbar multifidus muscle at rest and during a contralateral lower-limb lift (CLL) between older (60-85 years of age) and younger (18-40 years of age) adults. BACKGROUND Among younger adults, USI has been shown to be reliable and valid for assessing multifidus thickness. Older adults present with age-related changes that may impact assessment. To our knowledge, no USI studies have focused on establishing reliability for multifidus thickness assessments in older adults. METHODS Two examiners performed assessments of lumbar multifidus thickness at rest and during a CLL in 30 older and 31 younger adults. Intraclass correlation coefficient (ICC) with 95% confidence interval, standard error of measurement, 95% minimal detectable change for resting and during the CLL, and percent thickness change were calculated. RESULTS Within-day interexaminer procedural reliability for multifidus thickness measurements was similar among younger (ICC = 0.90-0.92) and older adults (ICC = 0.86-0.90), as was between-day intraexaminer and interexaminer reliability (younger adults, ICC = 0.84-0.94; older adults, ICC = 0.86-0.93). Throughout, estimates of percent thickness change were inconsistent (ICC = 0.31-0.86), and standard errors of measurement and minimal detectable changes were larger for older adults. CONCLUSION Ultrasound imaging reliability for measurements of multifidus thickness at rest and during a CLL among older adults is consistent with previously published findings for younger adults. Among older adults, it may be preferable to have a single examiner conduct USI assessments.

Trunk Muscle Training Augmented With Neuromuscular Electrical Stimulation Appears to Improve Function in Older Adults With Chronic Low Back Pain: A Randomized Preliminary Trial.

Objectives:To assess the feasibility of a trial to evaluate a trunk muscle training program augmented with neuromuscular electrical stimulation (TMT+NMES) for the rehabilitation of older adults with chronic low back pain (LBP) and to preliminarily investigate whether TMT+NMES could improve physical function and pain compared with a passive control intervention. Materials and Methods:We conducted a single-blind, randomized feasibility trial. Patients aged 60 to 85 years were allocated to TMT+NMES (n=31) or a passive control intervention (n=33), consisting of passive treatments, that is, heat, ultrasound, and massage. Outcomes assessed 3- and 6-month postrandomization included Timed Up and Go Test, gait speed, pain, and LBP-related functional limitation. Results:Feasibility was established by acceptable adherence (≥80%) and attrition (<20%) rates for both interventions. Both groups had similar, clinically important reductions in pain of >2 points on a numeric pain rating scale during the course of the trial. But, only the TMT+NMES group had clinically important improvements in both performance-based and self-reported measures of function. In terms of the participants’ global rating of functional improvement at 6 months, the TMT+NMES group improved by 73.9% and the passive control group improved by 56.7% compared with baseline. The between-group difference was 17.2% (95% confidence interval, 5.87-28.60) in favor of TMT+NMES. Discussion:It seems that a larger randomized trial investigating the efficacy of TMT+NMES for the purpose of improving physical function in older adults with chronic LBP is warranted.

Multifidi Muscle Characteristics and Physical Function Among Older Adults With and Without Chronic Low Back Pain

OBJECTIVE To determine whether multifidi size, intramuscular fat, or both, are associated with self-reported and performance-based physical function in older adults with and without chronic low back pain (LBP). DESIGN Case-control study. SETTING Individuals participated in a standardized evaluation in a clinical laboratory and underwent magnetic resonance imaging (MRI) of the lumbar spine at a nearby facility. PARTICIPANTS A volunteer sample of community-dwelling older adults (N=106), aged 60 to 85 years, with (n=57) and without (n=49) chronic LBP were included in this secondary data analysis. INTERVENTION Average right-left L5 multifidi relative (ie, total) cross-sectional area (CSA), muscle-fat infiltration index (MFI) (ie, a measure of intramuscular fat), and relative muscle CSA (rmCSA) (ie, total CSA minus intramuscular fat CSA) were determined from MRIs. Linear regression modeling was performed with physical function measures as the dependent variables. Age, sex, and body mass index were entered as covariates. The main effects of L5 multifidi MFI and rmCSA, as well as their interaction with group assignment, were compared as independent variables. MAIN OUTCOME MEASURES Medical Outcomes Study 36-Item Short-Form Health Survey physical functioning subscale, timed Up and Go, gait speed, and fast stair descent performance. RESULTS Interaction terms between L5 multifidi MFI and group assignment were found to be significant contributors to the variance explained in all physical function measures (P≤.012). Neither the main effect nor the interaction with group assignment for L5 multifidi rmCSA significantly contributed to the variance explained in any of the physical function measures (P>.012). CONCLUSIONS Among older adults with chronic LBP of at least moderate intensity, L5 multifidi muscle composition, but not size, may help to explain physical function.

Reliability of ultrasound imaging for the assessment of lumbar multifidi thickness in older adults with chronic low back pain.

Background and Purpose:Ultrasound imaging (USI) has been shown to be a reliable measure for direct assessment of the lumbar multifidi among younger adults. However, given age- and chronic low back pain (CLBP)-related spinal changes, similar studies are needed before clinical use of USI among older adults with CLBP. The goals of this study were to evaluate intra- and interexaminer reliability for USI assessment of multifidi thickness at rest and during a contraction and to determine standard error of measurement values (SEMs) and minimal detectable change values (MDCs) among older adults with CLBP. Methods:Thirty-one adults, aged 60 to 85 years, with CLBP were recruited. Two examiners performed USI assessments of multifidus thickness at rest and during a contralateral lower extremity lift. Intraclass correlation coefficients (ICCs) were used to estimate inter- and intraexaminer reliability. Additionally, SEMs and MDCs were calculated. Results:All USI measurement techniques demonstrated excellent within-day, interexaminer procedural reliability (ICCs: 0.82-0.85) and good-to-excellent between-day, interexaminer procedural reliability (ICCs: 0.72-0.79). The SEMs ranged from 0.36 to 0.46 cm; MDCs ranged from 1.01 to 1.26 cm. Regardless of the measurement technique, examiner 1, the more experienced examiner, demonstrated lower SEMs and MDCs than examiner 2. Discussion:Lower ICCs, greater SEMs, and greater MDCs for USI multifidus thickness assessment in older adults with CLBP, when compared with previously published, procedural reliability results for younger adults with and without low back pain, may indicate that imaging is more challenging in this patient population. Factors, such as examiner training and participant anthropometrics, may impact reliability. Conclusions:Good-to-excellent intra- and interexaminer USI procedural reliability may provide clinicians a direct assessment technique for clinical evaluation of the lumbar multifidi in older adults with CLBP. SEMs and MDCs may allow for accurate interpretation of USI assessments in this population.

Older Adults with Chronic Low Back Pain: A Clinical Population Vulnerable to Frailty?

The purpose of this secondary analysis was to explore the differences in proportions of frailty criteria, pre-frailty, and frailty in older adults with and without chronic low back pain (CLBP). Among individuals with CLBP, we also explored whether the proportions of these outcomes differed based on pain intensity status. Using measures to determine weakness, slowness, and exhaustion, we determined that older adults with CLBP had higher proportions of frailty criteria and were more likely to be classified as pre-frail or frail. Older adults with high intensity CLBP had greater proportions of weakness, exhaustion, and pre-frailty/frailty compared to those with low intensity CLBP. These preliminary findings suggest older adults with CLBP may be at a higher risk for frailty than those without pain; pain intensity may be an important factor in assessing risk of frailty in this population.

Lumbar Mobility and Performance-Based Function: An Investigation in Older Adults with and without Chronic Low Back Pain

Objective. To explore potential differences in lumbar mobility between older adults with and without chronic low back pain, and to determine if lumbar mobility contributes to physical performance in both groups. We hypothesized that older adults with pain would have greater lumbar mobility impairments than pain-free peers, and that lumbar mobility would be associated with performance in both groups, with stronger relationships among those with pain. Design. Matched case-control. Setting. Research laboratory. Patients. Community-dwelling older adults, aged 60–85 years, with (N = 54) and without (N = 54) chronic low back pain. Methods. Inclinometer-measured maximal angles of lumbar flexion, extension, and average side-bending, as well as time to complete performance measures, Repeated Chair Rise and Timed-Up-and-Go, were measured in both groups. Analysis of variance was used to explore the difference in lumbar mobility between groups. Adjusted linear regression was used to assess the independent relationship between lumbar mobility and physical function in both groups. Results. Those with pain had smaller angles of flexion (P = 0.029) and extension (P = 0.013). In the pain group, flexion explained 19% (P = 0.001) and 8.9% (P = 0.006) of the variance for time to complete the Repeated Chair Rise and Timed Up-and-Go tests, respectively. In the pain-free group, extension explained 12.7% (P = 0.007) and 10.3% (P = 0.008) of the variance for time to complete Repeated Chair Rise and Timed Up-and-Go tests, respectively. Conclusion. Older adults with chronic low back pain have more lumbar mobility impairments. Lumbar mobility may be a contributing factor to decreased performance in older adults. Flexion may be most important to performance in those with pain, while extension may be vital in those without pain.

Hip Symptoms, Physical Performance and Health Status in Older Adults with Chronic Low Back Pain: A Preliminary Investigation

OBJECTIVES To determine (1) whether there are differences in the prevalence of clinical hip symptoms between older adults with and without chronic low back pain (CLBP); and (2) whether coexisting hip symptoms are associated with worse physical performance and poorer health-related quality of life (HRQOL). DESIGN Case-control study. SETTING Individuals participated in a standardized evaluation in a clinical laboratory. PARTICIPANTS Clinical hip symptoms, which are proposed predictors of radiographic hip osteoarthritis according to American College of Rheumatology guidelines, were evaluated in a volunteer sample of community-dwelling older adults with CLBP (n=54; aged 60-85y) and in age- and sex-matched healthy controls (n=54). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Physical performance was measured by the repeated chair rise test and stair-climbing test. HRQOL was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). RESULTS Hip joint pain, morning stiffness, and pain with hip internal rotation were more common among older adults with CLBP (P<.05). Participants with CLBP and coexisting hip symptoms had worse physical performance than individuals without CLBP or hip symptoms (P<.0001). Additionally, the presence of coexisting hip symptoms was associated with worse HRQOL, particularly in the domains of social functioning, mental health, and role limitations attributable to emotional problems as measured by the SF-36 (P<.01). CONCLUSIONS Given our limited understanding of CLBP among older adults, there is a definitive need to systematically explore coexisting pain conditions that may contribute to worse outcomes. Based on these data, future longitudinal studies should explore whether coexisting hip symptoms are associated with a worse prognosis in older adults with CLBP.

Use of trunk muscle training and neuromuscular electrical stimulation to reduce pain and disability in an older adult with chronic low back pain: A case report

ABSTRACT Among older adults, low back pain (LBP) is common, costly, and disabling. Trunk muscle training (TMT) and neuromuscular electrical stimulation (NMES) have both been found to be effective in reducing LBP, but studies among older adults have been limited. An 83-year-old female with left-sided chronic LBP participated in a randomized controlled trial consisting of supervised TMT and NMES to the paraspinal muscles two times per week for 12 weeks. She also participated in a home exercise program. At the end of the intervention, she reported reduced LBP and LBP-related disability per the modified Oswestry disability index (i.e., 60% at baseline to 40% at 12 weeks). Her Short Physical Performance Battery summary score improved from 4/12 at baseline to 10/12 at 12 weeks, while her Timed Up and Go test improved from 17.21 to 15.20 s and her Repetitive Trunk Rotation test from 2.72 to 1.93 s/right–left rotation. This case demonstrates a positive short-term treatment response to TMT supplemented with NMES of the paraspinal muscles in an older adult with chronic LBP. A packaged intervention of TMT plus NMES may be a means of addressing not only LBP, but also impaired physical function and resultant disability.