Measuring inter-vertebral range of motion: how and why with clinical examples
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A presentation given to the Grand Rounds Radiology and Spinal meeting at Southern Upstate New York University. Syracuse. USA. June 2012
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Measuring inter-vertebral range of motion: how and why with clinical examples
- 1. How and Why: with examples of normative and patient data Fiona Mellor BSc (Hons). PhD Student. Research Radiographer/Associate Clinical Doctoral Research Fellow Institute for Musculoskeletal Research and Clinical Implementation Anglo-European College of Chiropractic/Bournemouth University U.K. e: imrci.fmellor@aecc.ac.uk
- 2. Objectives Place Bournemouth U.K. on the map Importance of inter-vertebral measurements Using QF to measure inter-vertebral motion Lumbar and Cervical spine Measurement parameters Case study Current research
- 6. Why measure intervertebral motion? Diagnosis Pseudarthrosis Mechanical low back pain: passive and active motion, palpation tests “Instability” Treatment Rehabilitation Research In vitro In vivo Disability American Medical Association: AOMSI
- 7. Past – Present - Future
- 9. Elastic zone f Deformation (degrees) Neutral zone lax normal Plastic zone Failure Almost all changes to the force (time)/deformation curve occur in the elastic zone. The neutral zone, taken as the slope of its initial climb under 2 kg of force, is largely linear. 2 kg Neutral Zone Theory
- 10. Quantitative Fluoroscopy Biomechanical Hypothesis
- 11. Quantitative Fluoroscopy In vivo Passive and active Lumbar and cervical spine Measurements include: Rotation Translation Instantaneous centres of rotation
- 12. The Bigger Picture Are there differences in the measurable spine kinematics of people with CNSLBP compared with those without? If so.. Are the factors in people with CNSLBP identifiable? If so... Do changes in them predict outcome? If so.. Can we change them?
- 13. Quantitative Fluoroscopy Acquisition Image Analysis Output
- 14. Image analysis
- 18. Translation Flexion (mm) Extension
- 19. Instantaneous Centre’s of Rotation (ICR’s)
- 20. Clinical example ICR’s in a degenerate spine
- 21. Case study: Female age 49 30 year history of non specific LBP which resolved from 2002 – 2010, then recurred after an RTA in March 2010. Prone pressure test (L5) positive. Original investigations (1993 x-ray then MRI) revealed grade 1 L5/S1 spondylolisthesis and L-S disc degeneration.
- 22. Case study: Female age 49
- 23. Case study: Female age 49 Rotation Left Right L1/2 4.69 2.88 L2/3 4.46 4 L3/4 3.83 3.69 L4/5 5.59 5.59 L5/S1 1.95 1.95 Flex Ext L1/2 2.13 4.33 L2/3 3.59 3.79 L3/4 4.55 2.14 L4/5 5.1 3.2 L5/S1 7.24 9.02
- 24. Case study: Female age 49 L5 Grade II spondylolisthesis with little or no degenerative change or other anomaly. Reduced extension rotational motion in upper lumbar segments with increased motion at the spondylolisthesis level in both flexion and extension. Normal directions and no laxity detected. However, total translational (flexion + extension) at L5-S1 was 4.9mm which, taking error into account, may border on abnormal.
- 25. Case study: Female age 49 Treatment: Patient wanted to avoid surgery. Extension mobilisation at the upper lumbar levels, 4 treatments over 2 months. Home rehab (foam roll) Maintain normal activity Outcome: Pain score reduced from 6/10 to 2/10 Normal activity resumed apart from fast swimming (aggravates extension)
- 26. QF research at AECC 1. Characteristics of lumbar spine intervertebral kinematics in healthy adults and their reproducibility over time N = 269 normative study N = 108 intra subject repeatability study Protocol: Trunk swing Age 21-71years Recumbent passive AND weight-bearing Coronal OR sagittal orientations
- 28. Passive Vs Active motion With kind permission from Orthokinematics.com
- 29. Healthy Passive Vs Active motion
- 30. Healthy recumbent passive flexion Inter-vertebral angle (o) Time (15 frames = 1 second)
- 31. Healthy weight-bearing flexion Time (15 frames = 1 second) Inter-vertebral angle (o)
- 32. QF Studies at AECC 2. Effects of manipulation of the cervical spine on inter-vertebral motion patterns and patient reported outcomes N = 60 (30 patients, 30 matched healthy volunteers). Baseline and 6 week Active guided motion
- 34. Cervical spine rotation in a patient with whiplash Flexion
- 35. Whiplash (flexion)Normal IAR location (Amevo et al, 1992) (n=46) C1-2 C2-3 C3-4 C4-5 C5-6 C6-7
- 36. PhD. Mid-lumbar inter-vertebral motion in participants with and without chronic non specific low back pain N = 80. (40 each group) Matched cohort for age, gender and BMI. Chronic Mechanical LBP > 3/12 duration Hip swing protocol 40o in each direction L2-L5
- 37. Outline Hypothesis: There will be a greater prevalence of ‘abnormal’ motion in those with CNSLBP than healthy controls. Abnormal defined as fixations (RoM < 3o) and increased laxity (Neutral Zone proxy) in first 10 degrees of trunk motion Analysis: Sensitivity and Specificity of abnormal motion
- 38. Results to date: Demographics Patients Controls N = 39 36 Age years (SD) 36.2 (8.4) 35.2 (8.4) % male 56% (n=22) 53% (n=19) BMI (SD) 24.8 (2.9) 24.5 (2.2)
- 39. Left Left Preliminary results Fiona Mellor PhD study
- 40. Results Preliminary results Fiona Mellor PhD study
- 41. Accuracy and Reliability Motion parameter Plane of motion Accuracy against calibration model (root mean square) Inter observer reliability (root mean square) Intra observer reliability (SEM) Intra subject variability (root mean square) Lumbar spine passive recumbent rotation (3) Coronal (left/right) 0.32o 1.86 o N/A (TBC) 2.75 o - 2.91 o Sagittal (flex/ext) 0.52 o 1.94 o N/A (TBC) N/A (TBC) Lumbar spine passive recumbent translation Flexion 0.6mm (10) 1.674mm (2) 1.427mm (2) N/A (TBC) Extension 0.79mm (10) 1.736mm (2) 1.958mm (2) N/A (TBC) Cervical spine active controlled motion (1) Flexion 0.21 o N/A (TBC) 0.52 o N/A (TBC) Extension 0.34 o N/A (TBC) 1.08 o N/A (TBC)
- 42. Radiation Dose Absorbed dose cGy.cm2 (SD) Calculated Effective dose mSv (SD) QF recumbent lumbar spine coronal and sagittal 613 (150) 0.561 (0.154) QF weight-bearing lumbar spine coronal and sagittal 662.9 (171) 0.77 (0.18) AP + Lateral lumbar spine radiograph 460 0.39 -1.2 Absorbed dose cGy.cm2 (SD) Calculated Effective dose mSv (SD) QF cervical spine sagittal 42.8 (9) 0.01 (0.003) Lateral cervical radiograph 0.012 Estimated effective dose (mSv) Transatlantic flight 0.07 CT head 1.4 UK annual background dose (average) 2.7 USA annual background dose (average) 6.2
- 44. References Breen, A. (2011). Quantitative fluoroscopy and the mechanics of the lumbar spine. Department of Medical Physics, Open University. MSc. Breen, A., Muggleton, J., Mellor, F. (2006). "An objective spinal motion imaging assessment (OSMIA): reliability, accuracy and exposure data." BMC Musculoskeletal Disorders 7(1): 1- 10. Hart, D., Hillier, M.A., Wall, B.F. (2005). Doses to patients from medical x-ray examinations in the UK. Review, National Radiation Protection Board (NRPB). Health Protection Agency (HPA). (2008). "Typical effective doses, equivalent periods of natural background radiation and lifetime fatal cancer risks from diagnostic medical exposures." Retrieved 13.03, 2012, from http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1195733826941. Health Protection Agency (HPA). (2009). "Recommended national reference doses for individual radiographs on adult patients - 2000 review." Retrieved 31.1.2012, from http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1195733771087. HPA. (2010). "Patient Dose information." Retrieved 24.08, 2010, from http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1195733826941. Mellor, F. E., J. M. Muggleton, et al. (2009). "Midlumbar Lateral Flexion Stability Measured in Healthy Volunteers by In Vivo Fluoroscopy." Spine 34(22): E811-E817. Mellor, F. E., P. Thomas, et al. (2012). "Radiation dose from quantitative fluoroscopy for investigating in vivo kinematics of the lumbar spine; compared to lumbar spine radiographs with suggestions for further dose reduction." British Journal of Radiology submitted. Van Loon, I., F. E. Mellor, et al. (2012). "Accuracy and repeatability of sagittal translation of lumbar vertebrae in vitro and in vivo using continuous quantitative fluoroscopy." Clinical Chiropractic Submitted.
- 45. Questions and Comments? Fiona Mellor E: imrci.fmellor@aecc.ac.uk Acknowledgements: National Institute of Health. Clinical Academic Training Fellowship. Bournemouth University Santander travel award. Anglo-European College of Chiropractic Orthokinematics Professor Alan Breen and the team at IMRCI Professor Nat Ordway and the team at SUNY
Editor's Notes
- Who I am and why I am here - Radiographer Thanks to BU, AECC and SUNY “Don’t teach your grandmother to suck eggs” – The notion of advising the young not to offer advice to those who are more experienced
- Background about the college and where I am from
- Bournemouth
- AECC history – grade 2 listed building built in 1889 as a catholic convent and school. Taken over by the AECC in 1982 and since expanded. The AECC was born in 1965 and was the first dedicated school of chiropractic in the UK. It began with just 14 students. Now we have over 500 enrolled onteh chiropractic MSC course and we also run a number of other undergraduate degrees such as exercise and sports science In 2009, the College opened a state of the art, purpose-built 1500m² teaching clinic boasting 34 treatment rooms, a high-tech functional exercise and rehabilitation centre, diagnostic ultrasound, x-ray and fluoroscopy. The clinic, one of the largest in Europe, has a well earned reputation for excellence in provision of chiropractic care to the local community, treating 55,000 people annually
- Mention that you are deliberately ignoring global measurements here such as goniometry and overall RoM because unreliable, audience knows about them (and it will make the presentation too long).
- Why measuring spinal motion is important, the past includes flex/ext/ Cut offs of 10 degrees/4mm for instability Cadaveric and RSA Fluoro – used as far back as 1952 (Brailsford) MRI – accessibility/affordability issues and not true dynamic motion
- What we know from cadavers
- From cadavers, but this uses force. Problem of applying this in vivo with movement substituted as force. That end RoM is not a useful measurement
- Biomech hyp (ignores psycho-social aspects). How motion is made up – and why studying passive lumbar motion is a link between cadaveric results and in vivo measurements
- What we primarily undertake at IMRCI (research dept of AECC) and the measurements we take
- How we do it (Moving back – i.e going back to x-rays but this time to measure function and not just quantity of motion)
- How we do it Start with the AP images and tracking templates, Insert the lateral flexion and left video of SimCol here where it shows tracking templates and begins with normal fluoro images but then swops to edge images to demonstrate image processing (Moving back – i.e going back to x-rays but this time to measure function and not just quantity of motion)
- The results are filtered to reduce noise and are displayed together showing left, right, flexion, extension. The reason its split is because we are looking for an in vivo way of measuring the neutral zone
- Talk about measuring the gradient of the IV slope in the first 10 degrees of trunk motion as a proxy/ in vitro NZ for laxity.
- From Alex’s MSc – accuracy and reliability Explain x an dy axis and that positive direction indicates anterior slip of superior vertebra.
- Can only measure ICRs when rotation is greater than 5 degrees. Has been validated (Alex’s MSC, can you get the figures?)
- Stiff in L1/2 and L2/3 in extension when compared to normative ranges (Pearcy et al). Irregular motion at L4/5 in extension but not reduced range overall (would have been reported as reduced if measured from flexion extension view). Flexion ranges were within normal parameters and all other motion patterns were normal
- Extension mobilisation to reduce the stress on L4/5 in extension which was irregular, and L5/S1 which was increased
- Fitting the symptoms to the motion patterns is dangerous when it is not known what normal is: Mention that Alan;s study is part of OrthoK?
- Important that range and rate is standardised to be able to make comparisons – and that the lack of standardisation has led to the large variaitons in reported IV angles so far
- With thanks to Ortho K
- What we do at AECC, erect, recumbent, normative, C spine and the studies we undertake (over a few slides)
- Make the point that this is 60 degrees flexion trunk motion to account for natural lordosis when erect
- Make the point that this is 60 degrees flexion trunk motion to account for natural lordosis when erect
- Accuracy and repeatability No validity/reliability stats for weight-bearing lumbar as yet Intra subject to be updated for passive, and created for weight-bearing based on existing data Intra subject variability for translation = have the data but not the manpower to track and analyse Largest error at the moment for rotation in lumbar spine is 2.91 degrees (the upper 95% C.I. of RMS) but this is based on old methods and is to be updated. Largest translation error is 2mm for passive extension.