Lumbar instability as an etiology of low back pain and its treatment by prolotherapy: A review

BACKGROUND: Low back pain is a significant spinal disorder that affects much of the population at some point during their lives. OBJECTIVE: While proper diagnosis is key, diagnosing the underlying cause of low back pain may often be unclear. METHOD: In this review article, we discuss lumbar instability as an etiology of low back pain and its treatment by prolotherapy. RESULTS: Spinal ligaments may be an underlying culprit in the development of lumbar instability with resultant low back pain and associated disorders. CONCLUSION: In these cases, adequate treatment consisting of non-biologic prolotherapy or cellular prolotherapy, including platelet rich plasma (PRP), can be beneficial in restoring spinal stability and resolving chronic low back pain.

A diagnostic tool for people with lumbar instability: a criterion-related validity study

Background Several clinical tests used to identify patients with lumbar instability have reported diagnostic accuracy in separate studies with conflicting results. To augment the diagnostic process, tests that are better able to identify lumbar instability suitable for use in the clinical setting are required. The aim of this study was to identify the probability to diagnose patients with lumbar instability, using x-ray imaging as the reference standard. Methods This study was a cross-sectional, diagnostic validity study. One hundred forty participants with chronic low back pain underwent an x-ray assessment and 14 clinical examinations. Data were analysed using multivariate regression methods to determine which clinical tests were most diagnostic for lumbar instability when they were applied together. Results Eighteen (12.85%) participants had radiological lumbar instability. Three clinical tests i) interspinous gap change during flexion-extension, ii) passive accessory intervertebral movement tests, iii) posterior shear test demonstrated an ability to diagnose lumbar instability of 67% when they were all positive. At this probability threshold, sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (−LR) were 5.56, 99.18%, 6.78, and 0.95. Conclusions These 3 clinical tests could be useful in identifying patients with lumbar instability in the general community. These three tests are simple to perform by physical therapists, reliable to use in a clinical setting, and safe for patients. We recommend physical therapists use these three tests to assess patients who are suspected of having lumbar instability, in the absence of an x-ray assessment, to receive appropriate targeted intervention or referral for further investigation. Trial registration Thai Clinial Trial Registry (TCTR 20180820001; 19th August 2018).

Validity of a Screening Tool for Patients with a Sub-Threshold Level of Lumbar Instability: A Cross-Sectional Study

Lumbar instability (LI) comprises one subgroup of those with chronic low back pain (CLBP); it indicates the impairment of at least one of the spinal stabilizing systems, and radiographic criteria of translation and rotation are used for its diagnosis. Previous studies have developed and tested a screening tool for LI where patients with sub-threshold lumbar instability (STLI) were detected in the initial stage of lumbar pathology using radiographs as a gold standard for diagnosis. The radiographic measurement in STLI lies between the range of translation and rotation of the LI and asymptomatic lumbar motion. However, there are no studies indicating the validity and cut-off points of the screening tool for STLI. The current study aimed to determine the validity of an LI screening tool to support the diagnostic process in patients with STLI. This study design was cross-sectional in nature. A total of 135 participants with CLBP, aged between 20 and 60 years, who had undergone flexion and extension radiographs, answered a screening tool with 14 questions. The cut-off score for identifying STLI using the screening tool was at least 6/14 positive responses to the LI questions. The findings suggested that the LI screening tool we tested is effective for the detection of STLI. The tool can be used in outpatient settings.

The Effects of Core Stabilization Exercise with the Abdominal Drawing-in Maneuver Technique versus General Strengthening Exercise on Lumbar Segmental Motion in Patients with Clinical Lumbar Instability: A Randomized Controlled Trial with 12-Month Follow-Up

Trunk stability exercises that focus on either deep or superficial muscles might produce different effects on lumbar segmental motion. This study compared outcomes in 34 lumbar instability patients in two exercises at 10 weeks and 12 months follow up. Participants were divided into either Core stabilization (deep) exercise, incorporating abdominal drawing-in maneuver technique (CSE with ADIM), or General strengthening (superficial) exercise (STE). Outcome measures were pain, muscle activation, and lumbar segmental motion. Participants in CSE with ADIM had significantly less pain than those in STE at 10 weeks. They showed significantly more improvement of abdominal muscle activity ratio than participants in STE at 10 weeks and 12 months follow-up. Participants in CSE with ADIM had significantly reduced sagittal translation at L4-L5 and L5-S1 compared with STE at 10 weeks. Participants in CSE with ADIM had significantly reduced sagittal translations at L4-L5 and L5-S1 compared with participants in STE at 10 weeks, whereas STE demonstrated significantly increased sagittal rotation at L4-L5. However, at 12 months follow-up, levels of lumbar sagittal translation were increased in both groups. CSE with ADIM which focuses on increasing deep trunk muscle activity can reduce lumbar segmental translation and should be recommended for lumbar instability.

Construction of Vertebral Body Tracking Algorithm Based on Dynamic Imaging Parameter Measurement and Its Application in the Treatment of Lumbar Instability

Static imaging measurements could not truly reflect the dynamic panorama of the lumbar movement process, and the abnormal activities between the lumbar vertebrae and their dynamic balance could not be observed, resulting in difficulties in the mechanism analysis of lumbar instability and the efficacy evaluation of manipulation therapy. Therefore, this paper constructed a vertebral tracking algorithm based on dynamic imaging parameter measurement through imaging parameter measurement and calculation. According to the imaging data obtained by vertebral body tracking algorithm, the corresponding statistical methods were used to compare the functional scores before and after manipulation and the changes of imaging data, so as to evaluate the therapeutic effect of manipulation on lumbar instability. Through the clinical observation and imaging analysis of 15 patients with lumbar instability before and after manipulation treatment, it is verified that the vertebra tracking algorithm is effective in the vertebra tracking and plays a positive role in the treatment of lumbar instability.

Effects of seated lumbar rotation manipulation in treating degenerative lumbar instability: a protocol for a randomized controlled trial

Background Degenerative lumbar instability (DLI) is a common disease that causes low back pain (LBP) in clinic. It is difficult to completely recover from DLI, and it occurs repeatedly, which seriously affects the quality of life of patients. The epidemiological survey showed that 20–30% of low back pain was related to lumbar instability. Increasing evidence shows that seated lumbar rotation manipulation can effectively improve the clinical symptoms of patients with low back pain. The primary aim of this clinical trial is to observe the intervention effect of seated lumbar rotation manipulation on DLI patients. Method/design A total of 60 participants with DLI will be recruited and randomly allocated into the seated lumbar rotation manipulation group (the intervention group) or lumbar traction in supine position group (the control group) in this prospective, outcome assessor-blind, two-arm randomized controlled clinical trial. The treatment of the two groups lasted for 3 weeks, and the manipulation of the intervention group would be carried out once every other day, three times a week, a total of 9 times; the control group would be given lumbar traction once a day, five times a week, a total of 15 times. JOA (Japanese Orthopaedic Association) and VAS (Visual Analogue Scales) scores will be recorded as the primary outcomes before the treatment and at the 1st, 3rd, 5th, 8th, 10th, 12th, 15th, 17th, and 19th days after treatment and follow-up visit at the first, third, and sixth months. JOA efficacy evaluation standard will be used to evaluate the overall efficacy as the secondary outcomes. Discussion The results of this prospective, randomized controlled trial will provide a clinical evidence for the treatment of DLI with seated lumbar rotation manipulation. Trial registration Chinese Clinical Trial Registry ChiCTR2000032017. Registered on 18 April 2020, Prospective registration.

Lumbar Instability Induces Ligamentum Flavum Hypertrophy in a Rat Model

Background: The purpose of this study was to establish a novel rat model for ligamentum flavum (LF) hypertrophy using lumbar instability and to elucidate the etiology of LF hypertrophy. Methods: A total number of 30 male rats were used. Lumbar instability was induced by surgical resection of L5/6 posterior elements (n=15). The other rats underwent a sham operation (n=15). After 8 weeks, all rats were taken lateral plain X-rays. The LF from L5/6 in both groups were harvested to investigate histological, immunohistological, and real-time PCR analysis. Results: According to radiological results, the disc height ratio and extension ratio were larger in the rats in the experimental group than that of in the control group. The HE staining showed that the LF thickness in the experimental group significantly increased in comparison to the control group. The Masson trichrome staining showed that the ratio of elastic fibers to collagen fibers in experimental group was lower than that in the control group. The protein and gene expression of TGF-β1, TNF-α, IL-1β, and Col 1 were significantly higher in the experimental group than that in the control group. Conclusion: It is the first time that lumbar instability directly induced LF hypertrophy in a reproducible rat model. Lumbar instability could lead to high expression of inflammatory and fibrotic factors in LF, causing the accumulation of collagen fibers and decreasing of elastic fibers.