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Journal of Back and Musculoskeletal Rehabilitation 00 (2014) 1–5 DOI 10.3233/BMR-140493 IOS Press
Posture of patients with lumbar spinal canal stenosis Aleksandra Truszczy´nskaa,b,c,∗, Justyna Drzał-Grabiecd , Maciej Płszewskia, Kazimierz Ra¸pałae and Adam Tarnowskif a
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Faculty of Physical Education and Sport in Biała Podlaska, Józef Piłsudski University of Physical Education, Warsaw, Poland b Professor A. Gruca Independent Public Research Hospital, Otwock Department of Orthopedic Surgery, Center of Postgraduate Medical Education, Otwock, Poland c Faculty of Rehabilitation, Józef Pilsudski University of Physical Education in Warsaw, Warsaw, Poland d Institute of Physiotherapy, University of Rzeszów, Poland e Social Academy of Science, Physiotherapy Faculty, Warsaw, Poland f Military Institute of Aviation Medicine, Psychology Department, Warsaw, Poland
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Abstract. BACKGROUND: The available literature is lacking in reports on the quantitative analysis of posture in patients with lumbar stenosis. OBJECTIVE: The aim of this study was to analyze body posture in patients with lumbar spinal canal stenosis. METHODS: The study involved 100 people: 49 persons with severe lumbar spine stenosis and 51 control subjects without any history of back pain. All participatants were evaluated by a photogrammetric method. RESULTS: Photogrammetric measurements showed statistically significant differences in the shape of the anterior-posterior curvatures of the spine. In the study group thoracic kyphosis was significantly greater (p = 0.043), and the depth of lumbar lordosis was significantly smaller (p = 0.038). The inclination of the thoracolumbar segment was also significantly lower (p = 0.013). CONCLUSIONS: 1. Measurements of body posture indicate a deepening of thoracic kyphosis and flattening of lumbar lordosis in lumbar stenosis patients. 2. Flattening of physiological lordosis seems to be caused by enlargment of the space of the spinal canal and dural sac in this position. Keywords: Spinal stenosis, lumbar spine, posture
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2 3 4 5 6
1. Introduction Lumbar stenosis is a narrowing of the spinal canal within the structures forming the wall of the spinal canal or a change in their shape, which reduces the volume of the canal and the nerve root formanina [1,2]. The narrowing can be caused by degenerative changes ∗ Corresponding
author: Aleksandra Truszczy´nska, Józef Piłsudski University of Physical Education in Warsaw, Faculty of Rehabilitation, Marymoncka St. 34, 00-968 Warsaw, Poland. E-mail: [email protected].
in intervertebral joints, herniated nucleus pulposus, thickening of yellow ligaments, degenerative spondylolisthesis, and congenital stenosis. Inflammation, tuberculosis and cancer of the spine can also result in narrowing of the spinal canal [3,4]. Stenosis of the spinal canal is manifested as back pain radiating to the lower extremities and neurogenic claudication [5]. Patients try to decompress the spine and the limb to which the pain radiates. Characteristically, patients with loss of lumbar lordosis accompanied, sometimes, by contralateral transposition of the body adopt a posture mostly in the opposite direction to the experienced
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pain [6]. Nevertheles, the available literature lacks reports on quantitative analysis of posture in patients with lumbar stenosis. Such studies would provide information on what type of posture predisposes human beings to stenosis of the spinal canal and what characteristics of the parameters characterizing the posture belong to risk factors.
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2. Aim of the study
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The aim of this study was to analyze body posture in patients with lumbar spinal canal stenosis.
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3. Material and methods
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The study involved 100 people. Group I included 49 persons with spinal stenosis of the lumbar spine hospitalized for this reason in the Department of Spinal Surgery, Medical Center of Postgraduate Education in Otwock. Group II comprised 51 control subjects without any history of back pain. The criteria for inclusion into the study: patients with clinical symptoms of spinal stenosis confirmed by radiographic imaging, patients with neurogenic claudication, neurological disorders of varying severity, and no improvement after physiotherapy. The criteria for disqualification of patients: lack of consent to examination, spondylolisthesis, other serious pathologies of the spine, inability to maintain an upright posture. The analyzed patients were aged 35–74 years, with a mean age of 54.62 (± 11.8) years; in the control group the corresponding numbers were 36–72 and 53.78 (± 5.7) years, respectively. The average weight of the patients in the study group was 78.56 (± 15.6) kg, with an average height of 166.56 (± 9.04) cm and, in the control group, the average subject’s weight was 74.3 (± 20.7) kg, with an average height of 168.29 (± 8.1) cm. Average BMI was 28.57 in Group I and 26.3 in Group II. None of these differences were statistically significant. To evaluate body posture the photogrammetric method was used, based on the phenomenon of the projection chamber. The tests involved anthropometric measurements based on images of the studied surface. The patient was positioned at a distance of 2.6 meters from the camera. The device projects lines of strictly defined parameters on the patient’s back, allowing a spatial image to be obtained. These lines reach the patient’s back
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Fig. 1. Sample results of the photogrammetric test.
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at a specific angle and are distorted depending on the distance to a given point from the device. Line image distortions are recorded by the computer using numerical algorithms to convert them into a contour map of the surface. In optics, the physical basis of this method is called the Moire phenomenon. Analysis, display, and printout of the test were performed using a computer program that allows transmission of the data to the statistical software. The study employed equipment and software from CQ Elektronik Systems. The analyses of the obtained photographs were made without the participation of the patients [7]. The study was conducted according to the recommendations given by the manufacturer, which were consistent with standard procedures [7]. The parameters described in Table 1 were used to elaborate this paper. The study design was approved by the Bioethics Committee of the University of Rzeszów. The study was conducted in the period from January to March 2013. Figure 1 shows some sample results of the photogrammetric test. Figure 2 presents the method of taking spine angle measurements. Statistical analysis. The independent variable (explanatory) was dichotomous, so the Student’s t-test for independent samples was used (with control of the homogeneity of variance using Levene’s test). The analysis was based on a two-sided significance level.
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Table 1 Parameters used to elaborate the paper Description Inclination of the lumbarsacral segment Inclination of the thoracolumbar segment Inclination of the upper thoracic segment Trunk inclination angle. Specifies the inclination of the body in the sagittal plane Thoracic kyphosis angle Depth of thoracic kyphosis Angle of lumbar lordosis Depth of lumbar lordosis Depth of the cervical spine
smaller in the study group, as evidenced by the differences in variances in Levene’s test (p = 0.038) and the differences in the mean results (p = 0.000). The study group was also characterized by a significantly lower inclination of the thoracolumbar segment, which was confirmed by the substantial difference in variances according to Levene’s test (p = 0.013) and a significant difference in the mean results (p = 0.000). Moreover, in most cases, the tested parameters were characterized by a high standard deviation, demonstrating the wide variation in the parameters in both groups. Other parameters examined during the course of the study did not show statistically significant differences.
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5. Discussion
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The obtained results of the measurements of body posture indicate a deepening of thoracic kyphosis and flattening of lumbar lordosis in patients with diagnosed stenosis. At the same time, an increase in the inclination of the thoracolumbar segment was observed. Flattening of physiological lordosis seems to be caused by enlargement of the space of the spinal canal and dural sac in this position. According to Tsuji et al. 2001, the posture of patients with lumbar pain syndromes is characterized by a decrease in lumbar lordosis, indicating that a reduction in the size of lumbar lordosis may predispose human beings to the occurrence of pain syndromes. This in turn may result – in the future – in the development of stenosis [8]. The interdependencies between spatial alignment of the spine in people without spinal symptoms and the dimensions of the spinal canal have been described by other researchers [9,10]. In a bent position, the surface of the spinal canal is the largest and its constriction occurs in positions involving a combination of extension and rotation. This is due to, among other factors, the increase in the thickness of the yellow ligaments in this position.
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Fig. 2. The method of taking spine angle measurements.
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Parameter ALFA BETA GAMMA KPT KKP GKP KLL GLL GKS
GKP KLL GLL
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92 93 94 95 96 97 98 99 100 101
SD 3,080 4,272 23,658 21,134 9,909 15,023 31,799 37,849 8,531 9,983
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Mean 4,049 7,261 148,385 138,095 3,769 10,563 186,795 189,298 −5,403 −13,656
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Table 2 Results of analysed statistically significant posture parameters
4. Results The results of the analysed statistically significant posture parameters are presented in Table 2. Photogrammetric measurements showed statistically significant differences in the shape of the anteriorposterior curvatures of the spine. Thoracic kyphosis was significantly greater in the study group, as evidenced by the Student’s t-test (p = 0.043) in the analysis of the angle and depth of thoracic kyphosis: Levene’s test (p = 0.012), t-test of equality of means (p = 0.019). The depth of lumbar lordosis was significantly
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Fig. 3. The pathomechanism of the phenomenon of lumbar lordosis loss in ankylosing spondylitis.
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with the most important clinical and functional parameters. The results suggest that posture assessment and effective correction of possible irregularities in body alignment should be a standard part of functional training [19]. Sawacha et al. 2012 conducted a quantitative assessment of kinematic parameters and body balance in twelve patients with ankylosing spondylitis using a stereophotogrammetric system equipped with six cameras and a tensometric platform. The researchers stressed the need to study both body posture and balance in patients with ankylosing spondylitis, which may assist clinicians in planning physiotherapy [20]. Clinical experience shows that ankylosing spondylitis is also associated with loss of lumbar lordosis. The pathomechanism of this phenomenon is explained in Fig. 3. The sacrum is situated in forward flexion in relation to the ilium. Its position is stabilised by strong ligaments. The inflammation of sacroiliac joints causes pain. To relieve the pressure from inflammed iliotrochanteric ligaments, the patient changes the orientation of the sacrum from an inclined to a more vertical one. This posterior pelvic tilt relaxes the ligaments, leading to pain relief. Limitations of the research. The study group was not a large one. The study was prospective, but it was not possible to design a randomized study. The value of the research. The authors do not know of any earlier reports on posture in patients with spinal stenosis. This study is the first research work characterizing specific parameters of body posture in patients with stenosis. The study involved a relatively homogeneous group of patients with uniform diagnosis of spinal canal stenosis. The comparison of body posture in the study group and in the control subjects showsedsignificant differences in parameters charac-
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The problem of narrowing of the spinal canal and the spinal canal surface in patients with stenosis has been described in studies using digital computed tomography [11,12]. Goldman et al., 2008, studied the effects of trunk inclination and spinal decompression through the use of a four-wheel walker in patients with neurogenic claudication. They observed an improvement in physical efficiency in more than half of the subjects [13]. An interesting study on the impact of position and spinal unloading on neurogenic claudication distance, measured during walking on a treadmill, was conducted by Oguz et al. [14]. The researchers found that the claudication distance is affected by the unloading of the spine and the position is not statistically significant. Reduced lumbar lordosis is also observed in patients with stenosis in the course of degenerative spondylolisthesis. Beneficial effects of the kyphotic setting of the lumbar segment on the surface of the spinal canal, and thus on the increase in its volume, are caused by improved blood circulation in compressed nerve structures, which leads to a decrease in the severity of neurological symptoms of neurogenic claudication. This has been confirmed by experimental studies [15,16]. Miao, based on three-dimensional CT or MR imaging, reconstructed segments of spines in patients diagnosed with degenerative spondylolisthesis and in a control group of patients. The author showed that in both groups, the volume of the spinal canal was larger in the supine and flexed positions compared to the standing and extension positions. The increased volume of the spinal canal in the supine and flexed positions may explain the observed clinical reduction in symptoms observed in patients with degenerative spondylolisthesis while adopting such postures [17]. The adverse effect of the upright position on the width of the spinal canal was also analyzed by BenGalim and Reitman 2006. The authors conducted MRI tests and myelography in subjects who assumed a standing position, and recorded that in all these patients myelography showed they had very clear spinal stenosis, dependent upon the standing position, with spondylolisthesis of Grade I or II, whereas the MRI examination showed very little or no spondylolisthesis [18]. The importance of posture assessment in other spinal disorders was highlighted by Rosu et al., 2012, who conducted a screening test of patients with diagnosed ankylosing spondylitis (AS) to evaluate static disorders of the spine and correlate the obtained results
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6. Conclusions
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Measurements of body posture indicated a statistically significant deepening of thoracic kyphosis, flattening of lumbar lordosis and lower inclination of the thoracolumbar segment in patients with diagnosed lubar spine stenosis compared to an unaffected control group. Flattening of physiological lordosis seems to be caused by enlargement of the space of the spinal canal and dural sac in this position, which decompresses neural structures and enables temporary pain relief.
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Acknowledgements
The paper was prepared as part of the statutory research program No. DS.168 of WWFiS in Bia¸sa Podlaska and was sponsored by the Ministry of Science and Higher Education, Poland.
References [1]
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[2]
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[3]
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Botwin KP, Gruber RD. Review Lumbar spinal stenosis: Anatomy and pathogenesis. Phys Med Rehabil Clin N Am. 2003; 14(1):1-15. Truszczy´nska A, Ra¸pała K, Truszczy´nski O, Tarnowski A, kawski St. Return to work after spinal stenosis surgery and patients’ quality of life. IJOMEH 2013;26(3):1-7. Ra¸pała K, Walczak P, Truszczy´nska A, cˇ ukawski St, NowakMisiak M: Diagnostic and therapeutic problems of back pain syndromes and their distribution according to a colour coding system of flags. Ortop, Traumat Rehab 2012;3: 215-228. Truszczy´nska A, Nowak-Misiak M, Ra¸pała K, Walczak P,: Tuberculosis of the spine masquerading as a spine lymphoma. A Case Report and Discussion of Diagnostic and Therapeutic
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Traps 2013;47;2:189-193. Conrad BP, Shokat MS, Abbasi AZ, Vincent HK, Seay A, Kennedy DJ. Associations of self-report measures with gait, range of motion and proprioception in patients with lumbar spinal stenosis. Gait Posture 2013;38(4):987-92. [6] Chad DA. Review Lumbar spinal stenosis. Neurol Clin 2007; 25(2):407-18. [7] Drzal-Grabiec J, Snela S. The influence of rural environment on body posture. Ann Agric Environ Med 2012; 19(4):846850. [8] Tsuji T, Matsuyama Y, Sato K, Hasegawa Y, Yimin Y, Iwata H. Epidemiology of low back pain in the elderly: correlation with lumbar lordosis. J Orthop Sci. 2001;6(4):307-11. [9] Chung SS, Lee CS, Kim SH, Chung MW, Ahn JM. Effect of low back posture on the morphology of the spinal canal. Skeletal Radiol. 2000;29(4):217-23. [10] Hirasawa Y, Bashir WA, Smith FW, Magnusson ML, Pope MH, Takahashi K. Postural changes of the dural sac in the lumbar spines of asymptomatic individuals using positional stand-up magnetic resonance imaging. Spine (Phila Pa 1976). 2007;15;32(4):E136-40. [11] Ra¸pała K, Chaberek S, Truszczy´nska A, Lukawski St, Walczak P.: Assessment of lumbar spinal canal morphology with digital computed tomography. Ortop Traumat Rehab 2009; 11(2):156-163. [12] Melancia JL, Francisco AF, Antunes JL. Spinal stenosis. Handb Clin Neurol. 2014;119:541-9. [13] Goldman SM, Barice EJ, Schneider WR, Hennekens CH.: Lumbar spinal stenosis: can positional therapy alleviate pain? J Fam Pract. 2008;57(4):257-60. [14] O˘guz H, Levendo˘glu F, O˘gün TC, Tantu˘g A. Loading is more effective than posture in lumbar spinal stenosis: a study with a treadmill equipment. Eur Spine J. 2007;16(7):913-8. [15] Takenobu Y, Katsube N, Marsala M, Kondo K. Model of neuropathic intermittent claudication in the rat: methodology and application. J Neurosci Methods. 2001; 15;104(2):191-8. [16] Liu X, Wang H, Ji S, Yuzhi Z, Wang H.: Blood flow changes of cauda equina in experimental lumbar spinal canal stenosis under dynamic burden. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2004;18(5):406-8. [17] Miao J, Wang S, Park WM, Xia Q, Fang X, Toriani MP, Wood KB, Li G. Segmental spinal canal volume in patients with degenerative spondylolisthesis. 2013;13(6):706-12. [18] Ben-Galim P, Reitman CA. The distended facet sign: an indicator of position-dependent spinal stenosis and degenerative spondylolisthesis. Spine J. 2007;7(2):245-8. [19] Ro¸su MO, Ancu¸ta C, Iordache C, Chirieac R. Importance of posture assessment in ankylosing spondylitis. Preliminary study. Rev Med Chir Soc Med Nat Iasi. 2012; 116 (3): 780-4. [20] Sawacha Z, Carraro E, Del Din S, Guiotto A, Bonaldo L, Punzi L, Cobelli C, Masiero S. Biomechanical assessment of balance and posture in subjects with ankylosing spondylitis. J Neuroeng Rehabil. 2012: 29;9:63. [5]
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terizing body posture. This may contribute to the prevention of pain occurring in the lumbar spine and the determination of an ergonomic posture, especially since the prevalence of spinal canal stenosis is likely to increase due to extending life spans. Further research could present a prospective analysis of posture in patients diagnosed with early symptoms of stenosis.
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Journal of Back and Musculoskeletal Rehabilitation 00 (2014) 1–5 DOI 10.3233/BMR-140493 IOS Press
Posture of patients with lumbar spinal canal stenosis Aleksandra Truszczy´nskaa,b,c,∗, Justyna Drzał-Grabiecd , Maciej Płszewskia, Kazimierz Ra¸pałae and Adam Tarnowskif a
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Faculty of Physical Education and Sport in Biała Podlaska, Józef Piłsudski University of Physical Education, Warsaw, Poland b Professor A. Gruca Independent Public Research Hospital, Otwock Department of Orthopedic Surgery, Center of Postgraduate Medical Education, Otwock, Poland c Faculty of Rehabilitation, Józef Pilsudski University of Physical Education in Warsaw, Warsaw, Poland d Institute of Physiotherapy, University of Rzeszów, Poland e Social Academy of Science, Physiotherapy Faculty, Warsaw, Poland f Military Institute of Aviation Medicine, Psychology Department, Warsaw, Poland
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Abstract. BACKGROUND: The available literature is lacking in reports on the quantitative analysis of posture in patients with lumbar stenosis. OBJECTIVE: The aim of this study was to analyze body posture in patients with lumbar spinal canal stenosis. METHODS: The study involved 100 people: 49 persons with severe lumbar spine stenosis and 51 control subjects without any history of back pain. All participatants were evaluated by a photogrammetric method. RESULTS: Photogrammetric measurements showed statistically significant differences in the shape of the anterior-posterior curvatures of the spine. In the study group thoracic kyphosis was significantly greater (p = 0.043), and the depth of lumbar lordosis was significantly smaller (p = 0.038). The inclination of the thoracolumbar segment was also significantly lower (p = 0.013). CONCLUSIONS: 1. Measurements of body posture indicate a deepening of thoracic kyphosis and flattening of lumbar lordosis in lumbar stenosis patients. 2. Flattening of physiological lordosis seems to be caused by enlargment of the space of the spinal canal and dural sac in this position. Keywords: Spinal stenosis, lumbar spine, posture
1
2 3 4 5 6
1. Introduction Lumbar stenosis is a narrowing of the spinal canal within the structures forming the wall of the spinal canal or a change in their shape, which reduces the volume of the canal and the nerve root formanina [1,2]. The narrowing can be caused by degenerative changes ∗ Corresponding
author: Aleksandra Truszczy´nska, Józef Piłsudski University of Physical Education in Warsaw, Faculty of Rehabilitation, Marymoncka St. 34, 00-968 Warsaw, Poland. E-mail: [email protected].
in intervertebral joints, herniated nucleus pulposus, thickening of yellow ligaments, degenerative spondylolisthesis, and congenital stenosis. Inflammation, tuberculosis and cancer of the spine can also result in narrowing of the spinal canal [3,4]. Stenosis of the spinal canal is manifested as back pain radiating to the lower extremities and neurogenic claudication [5]. Patients try to decompress the spine and the limb to which the pain radiates. Characteristically, patients with loss of lumbar lordosis accompanied, sometimes, by contralateral transposition of the body adopt a posture mostly in the opposite direction to the experienced
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pain [6]. Nevertheles, the available literature lacks reports on quantitative analysis of posture in patients with lumbar stenosis. Such studies would provide information on what type of posture predisposes human beings to stenosis of the spinal canal and what characteristics of the parameters characterizing the posture belong to risk factors.
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2. Aim of the study
27 28
The aim of this study was to analyze body posture in patients with lumbar spinal canal stenosis.
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3. Material and methods
30
The study involved 100 people. Group I included 49 persons with spinal stenosis of the lumbar spine hospitalized for this reason in the Department of Spinal Surgery, Medical Center of Postgraduate Education in Otwock. Group II comprised 51 control subjects without any history of back pain. The criteria for inclusion into the study: patients with clinical symptoms of spinal stenosis confirmed by radiographic imaging, patients with neurogenic claudication, neurological disorders of varying severity, and no improvement after physiotherapy. The criteria for disqualification of patients: lack of consent to examination, spondylolisthesis, other serious pathologies of the spine, inability to maintain an upright posture. The analyzed patients were aged 35–74 years, with a mean age of 54.62 (± 11.8) years; in the control group the corresponding numbers were 36–72 and 53.78 (± 5.7) years, respectively. The average weight of the patients in the study group was 78.56 (± 15.6) kg, with an average height of 166.56 (± 9.04) cm and, in the control group, the average subject’s weight was 74.3 (± 20.7) kg, with an average height of 168.29 (± 8.1) cm. Average BMI was 28.57 in Group I and 26.3 in Group II. None of these differences were statistically significant. To evaluate body posture the photogrammetric method was used, based on the phenomenon of the projection chamber. The tests involved anthropometric measurements based on images of the studied surface. The patient was positioned at a distance of 2.6 meters from the camera. The device projects lines of strictly defined parameters on the patient’s back, allowing a spatial image to be obtained. These lines reach the patient’s back
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Fig. 1. Sample results of the photogrammetric test.
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at a specific angle and are distorted depending on the distance to a given point from the device. Line image distortions are recorded by the computer using numerical algorithms to convert them into a contour map of the surface. In optics, the physical basis of this method is called the Moire phenomenon. Analysis, display, and printout of the test were performed using a computer program that allows transmission of the data to the statistical software. The study employed equipment and software from CQ Elektronik Systems. The analyses of the obtained photographs were made without the participation of the patients [7]. The study was conducted according to the recommendations given by the manufacturer, which were consistent with standard procedures [7]. The parameters described in Table 1 were used to elaborate this paper. The study design was approved by the Bioethics Committee of the University of Rzeszów. The study was conducted in the period from January to March 2013. Figure 1 shows some sample results of the photogrammetric test. Figure 2 presents the method of taking spine angle measurements. Statistical analysis. The independent variable (explanatory) was dichotomous, so the Student’s t-test for independent samples was used (with control of the homogeneity of variance using Levene’s test). The analysis was based on a two-sided significance level.
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Table 1 Parameters used to elaborate the paper Description Inclination of the lumbarsacral segment Inclination of the thoracolumbar segment Inclination of the upper thoracic segment Trunk inclination angle. Specifies the inclination of the body in the sagittal plane Thoracic kyphosis angle Depth of thoracic kyphosis Angle of lumbar lordosis Depth of lumbar lordosis Depth of the cervical spine
smaller in the study group, as evidenced by the differences in variances in Levene’s test (p = 0.038) and the differences in the mean results (p = 0.000). The study group was also characterized by a significantly lower inclination of the thoracolumbar segment, which was confirmed by the substantial difference in variances according to Levene’s test (p = 0.013) and a significant difference in the mean results (p = 0.000). Moreover, in most cases, the tested parameters were characterized by a high standard deviation, demonstrating the wide variation in the parameters in both groups. Other parameters examined during the course of the study did not show statistically significant differences.
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5. Discussion
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The obtained results of the measurements of body posture indicate a deepening of thoracic kyphosis and flattening of lumbar lordosis in patients with diagnosed stenosis. At the same time, an increase in the inclination of the thoracolumbar segment was observed. Flattening of physiological lordosis seems to be caused by enlargement of the space of the spinal canal and dural sac in this position. According to Tsuji et al. 2001, the posture of patients with lumbar pain syndromes is characterized by a decrease in lumbar lordosis, indicating that a reduction in the size of lumbar lordosis may predispose human beings to the occurrence of pain syndromes. This in turn may result – in the future – in the development of stenosis [8]. The interdependencies between spatial alignment of the spine in people without spinal symptoms and the dimensions of the spinal canal have been described by other researchers [9,10]. In a bent position, the surface of the spinal canal is the largest and its constriction occurs in positions involving a combination of extension and rotation. This is due to, among other factors, the increase in the thickness of the yellow ligaments in this position.
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Fig. 2. The method of taking spine angle measurements.
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Parameter ALFA BETA GAMMA KPT KKP GKP KLL GLL GKS
GKP KLL GLL
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92 93 94 95 96 97 98 99 100 101
SD 3,080 4,272 23,658 21,134 9,909 15,023 31,799 37,849 8,531 9,983
rre
Mean 4,049 7,261 148,385 138,095 3,769 10,563 186,795 189,298 −5,403 −13,656
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KKP
N 49 51 49 51 49 51 49 51 49 51
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BETA
Group 1 2 1 2 1 2 1 2 1 2
ct
Table 2 Results of analysed statistically significant posture parameters
4. Results The results of the analysed statistically significant posture parameters are presented in Table 2. Photogrammetric measurements showed statistically significant differences in the shape of the anteriorposterior curvatures of the spine. Thoracic kyphosis was significantly greater in the study group, as evidenced by the Student’s t-test (p = 0.043) in the analysis of the angle and depth of thoracic kyphosis: Levene’s test (p = 0.012), t-test of equality of means (p = 0.019). The depth of lumbar lordosis was significantly
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151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189
Fig. 3. The pathomechanism of the phenomenon of lumbar lordosis loss in ankylosing spondylitis.
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with the most important clinical and functional parameters. The results suggest that posture assessment and effective correction of possible irregularities in body alignment should be a standard part of functional training [19]. Sawacha et al. 2012 conducted a quantitative assessment of kinematic parameters and body balance in twelve patients with ankylosing spondylitis using a stereophotogrammetric system equipped with six cameras and a tensometric platform. The researchers stressed the need to study both body posture and balance in patients with ankylosing spondylitis, which may assist clinicians in planning physiotherapy [20]. Clinical experience shows that ankylosing spondylitis is also associated with loss of lumbar lordosis. The pathomechanism of this phenomenon is explained in Fig. 3. The sacrum is situated in forward flexion in relation to the ilium. Its position is stabilised by strong ligaments. The inflammation of sacroiliac joints causes pain. To relieve the pressure from inflammed iliotrochanteric ligaments, the patient changes the orientation of the sacrum from an inclined to a more vertical one. This posterior pelvic tilt relaxes the ligaments, leading to pain relief. Limitations of the research. The study group was not a large one. The study was prospective, but it was not possible to design a randomized study. The value of the research. The authors do not know of any earlier reports on posture in patients with spinal stenosis. This study is the first research work characterizing specific parameters of body posture in patients with stenosis. The study involved a relatively homogeneous group of patients with uniform diagnosis of spinal canal stenosis. The comparison of body posture in the study group and in the control subjects showsedsignificant differences in parameters charac-
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The problem of narrowing of the spinal canal and the spinal canal surface in patients with stenosis has been described in studies using digital computed tomography [11,12]. Goldman et al., 2008, studied the effects of trunk inclination and spinal decompression through the use of a four-wheel walker in patients with neurogenic claudication. They observed an improvement in physical efficiency in more than half of the subjects [13]. An interesting study on the impact of position and spinal unloading on neurogenic claudication distance, measured during walking on a treadmill, was conducted by Oguz et al. [14]. The researchers found that the claudication distance is affected by the unloading of the spine and the position is not statistically significant. Reduced lumbar lordosis is also observed in patients with stenosis in the course of degenerative spondylolisthesis. Beneficial effects of the kyphotic setting of the lumbar segment on the surface of the spinal canal, and thus on the increase in its volume, are caused by improved blood circulation in compressed nerve structures, which leads to a decrease in the severity of neurological symptoms of neurogenic claudication. This has been confirmed by experimental studies [15,16]. Miao, based on three-dimensional CT or MR imaging, reconstructed segments of spines in patients diagnosed with degenerative spondylolisthesis and in a control group of patients. The author showed that in both groups, the volume of the spinal canal was larger in the supine and flexed positions compared to the standing and extension positions. The increased volume of the spinal canal in the supine and flexed positions may explain the observed clinical reduction in symptoms observed in patients with degenerative spondylolisthesis while adopting such postures [17]. The adverse effect of the upright position on the width of the spinal canal was also analyzed by BenGalim and Reitman 2006. The authors conducted MRI tests and myelography in subjects who assumed a standing position, and recorded that in all these patients myelography showed they had very clear spinal stenosis, dependent upon the standing position, with spondylolisthesis of Grade I or II, whereas the MRI examination showed very little or no spondylolisthesis [18]. The importance of posture assessment in other spinal disorders was highlighted by Rosu et al., 2012, who conducted a screening test of patients with diagnosed ankylosing spondylitis (AS) to evaluate static disorders of the spine and correlate the obtained results
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Measurements of body posture indicated a statistically significant deepening of thoracic kyphosis, flattening of lumbar lordosis and lower inclination of the thoracolumbar segment in patients with diagnosed lubar spine stenosis compared to an unaffected control group. Flattening of physiological lordosis seems to be caused by enlargement of the space of the spinal canal and dural sac in this position, which decompresses neural structures and enables temporary pain relief.
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Acknowledgements
The paper was prepared as part of the statutory research program No. DS.168 of WWFiS in Bia¸sa Podlaska and was sponsored by the Ministry of Science and Higher Education, Poland.
References [1]
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[3]
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Botwin KP, Gruber RD. Review Lumbar spinal stenosis: Anatomy and pathogenesis. Phys Med Rehabil Clin N Am. 2003; 14(1):1-15. Truszczy´nska A, Ra¸pała K, Truszczy´nski O, Tarnowski A, kawski St. Return to work after spinal stenosis surgery and patients’ quality of life. IJOMEH 2013;26(3):1-7. Ra¸pała K, Walczak P, Truszczy´nska A, cˇ ukawski St, NowakMisiak M: Diagnostic and therapeutic problems of back pain syndromes and their distribution according to a colour coding system of flags. Ortop, Traumat Rehab 2012;3: 215-228. Truszczy´nska A, Nowak-Misiak M, Ra¸pała K, Walczak P,: Tuberculosis of the spine masquerading as a spine lymphoma. A Case Report and Discussion of Diagnostic and Therapeutic
un
235
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233
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Traps 2013;47;2:189-193. Conrad BP, Shokat MS, Abbasi AZ, Vincent HK, Seay A, Kennedy DJ. Associations of self-report measures with gait, range of motion and proprioception in patients with lumbar spinal stenosis. Gait Posture 2013;38(4):987-92. [6] Chad DA. Review Lumbar spinal stenosis. Neurol Clin 2007; 25(2):407-18. [7] Drzal-Grabiec J, Snela S. The influence of rural environment on body posture. Ann Agric Environ Med 2012; 19(4):846850. [8] Tsuji T, Matsuyama Y, Sato K, Hasegawa Y, Yimin Y, Iwata H. Epidemiology of low back pain in the elderly: correlation with lumbar lordosis. J Orthop Sci. 2001;6(4):307-11. [9] Chung SS, Lee CS, Kim SH, Chung MW, Ahn JM. Effect of low back posture on the morphology of the spinal canal. Skeletal Radiol. 2000;29(4):217-23. [10] Hirasawa Y, Bashir WA, Smith FW, Magnusson ML, Pope MH, Takahashi K. Postural changes of the dural sac in the lumbar spines of asymptomatic individuals using positional stand-up magnetic resonance imaging. Spine (Phila Pa 1976). 2007;15;32(4):E136-40. [11] Ra¸pała K, Chaberek S, Truszczy´nska A, Lukawski St, Walczak P.: Assessment of lumbar spinal canal morphology with digital computed tomography. Ortop Traumat Rehab 2009; 11(2):156-163. [12] Melancia JL, Francisco AF, Antunes JL. Spinal stenosis. Handb Clin Neurol. 2014;119:541-9. [13] Goldman SM, Barice EJ, Schneider WR, Hennekens CH.: Lumbar spinal stenosis: can positional therapy alleviate pain? J Fam Pract. 2008;57(4):257-60. [14] O˘guz H, Levendo˘glu F, O˘gün TC, Tantu˘g A. Loading is more effective than posture in lumbar spinal stenosis: a study with a treadmill equipment. Eur Spine J. 2007;16(7):913-8. [15] Takenobu Y, Katsube N, Marsala M, Kondo K. Model of neuropathic intermittent claudication in the rat: methodology and application. J Neurosci Methods. 2001; 15;104(2):191-8. [16] Liu X, Wang H, Ji S, Yuzhi Z, Wang H.: Blood flow changes of cauda equina in experimental lumbar spinal canal stenosis under dynamic burden. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2004;18(5):406-8. [17] Miao J, Wang S, Park WM, Xia Q, Fang X, Toriani MP, Wood KB, Li G. Segmental spinal canal volume in patients with degenerative spondylolisthesis. 2013;13(6):706-12. [18] Ben-Galim P, Reitman CA. The distended facet sign: an indicator of position-dependent spinal stenosis and degenerative spondylolisthesis. Spine J. 2007;7(2):245-8. [19] Ro¸su MO, Ancu¸ta C, Iordache C, Chirieac R. Importance of posture assessment in ankylosing spondylitis. Preliminary study. Rev Med Chir Soc Med Nat Iasi. 2012; 116 (3): 780-4. [20] Sawacha Z, Carraro E, Del Din S, Guiotto A, Bonaldo L, Punzi L, Cobelli C, Masiero S. Biomechanical assessment of balance and posture in subjects with ankylosing spondylitis. J Neuroeng Rehabil. 2012: 29;9:63. [5]
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terizing body posture. This may contribute to the prevention of pain occurring in the lumbar spine and the determination of an ergonomic posture, especially since the prevalence of spinal canal stenosis is likely to increase due to extending life spans. Further research could present a prospective analysis of posture in patients diagnosed with early symptoms of stenosis.
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