Treatment of lumbar disc herniation: Evidence-based practice

Andrew J Schoenfeld1, Bradley K Weiner21Department of Orthopedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, El Paso, TX, USA; 2Weill Cornell Medical College and The Methodist Hospital, Houston, TX, USAClinical question: What is the best treatment for lumbar disc herniations? Results: For patients failing six weeks of conservative care, the current literature supports surgical intervention or prolonged conservative management as appropriate treatment options for lumbar radiculopathy in the setting of disc herniation. Surgical intervention may result in more rapid relief of symptoms and restoration of function.Implementation: While surgery appears to provide more rapid relief, many patients will gradually get better with continued nonoperative management; thus, patient education and active participation in decision-making is vital.Keywords: lumbar disc, herniation, back pain, spin

Dose-response modelling of resistance exercise across outcome domains in strength and conditioning: a meta-analysis.

Resistance exercise is the most common training modality included within strength and conditioning (S&C) practice. Understanding dose-response relationships between resistance training and a range of outcomes relevant to physical and sporting performance is of primary importance for quality S&C prescription. The aim of this meta-analysis was to use contemporary modelling techniques to investigate resistance-only and resistance-dominant training interventions, and explore relationships between training variables (frequency, volume, intensity), participant characteristics (training status, sex) and improvements across a range of outcome domains including maximum strength, power, vertical jump, change of direction, and sprinting performance. Data were obtained from a database of training studies conducted between 1962-2018, which comprised healthy trained or untrained adults engaged in resistance-only or resistance-dominant interventions. Studies were not required to include a control group. Standardized mean difference effect sizes were calculated and interventions categorized according to a range of training variables describing frequency (number of sessions per week), volume (number of sets and repetitions performed), overall intensity (intensity of effort and load, categorised as low, medium, or high), and intensity of load (represented as % 1RM prescribed). Contemporary modelling techniques including Bayesian mixed effects meta-analytic models were fitted to investigate linear and non-linear dose-responses with models compared based on predictive accuracy. Data from a total of 295 studies comprising 535 groups and 6710 participants were included with analyses conducted on time points ≤26 weeks. The best performing model included: duration from baseline, average number of sets, and the main and interaction effects between outcome domain and intensity of load (%1RM) expressed non-linearly. Model performance was not improved by the inclusion of participant training status or sex. The current meta-analysis represents the most comprehensive investigation of dose-response relationships across a range of outcome domains commonly targeted within strength and conditioning to date. Results demonstrate the magnitude of improvements are predominantly influenced by training intensity of load and the outcome measured. When considering the effects of intensity as a %1RM, profiles differ across outcome domains with maximum strength likely to be maximised with the heaviest loads, vertical jump performance likely to be maximised with relatively light loads (~30%1RM), and power likely to be maximised with low to moderate loads (40-70% 1RM)

Modification of Otolith Reflex Asymmetries Following Space Flight

We hypothesize that changes in otolith-mediated reflexes adapted for microgravity contribute to perceptual, gaze and postural disturbances upon return to Earth s gravity. Our goal was to determine pre- versus post-fight differences in unilateral otolith reflexes that reflect these adaptive changes. This study represents the first comprehensive examination of unilateral otolith function following space flight. Ten astronauts participated in unilateral otolith function tests three times pre-flight and up to four times after Shuttle flights from landing day through the subsequent 10 days. During unilateral centrifugation (UC, +/- 3.5cm at 400deg/s), utricular function was examined by the perceptual changes reflected by the subjective visual vertical (SVV) and by video-oculographic measurement of the otolith-mediated ocular counter-roll (OOR). Unilateral saccular reflexes were recorded by measurement of collic Vestibular Evoked Myogenic Potential (cVEMP). Although data from a few subjects were not obtained early post-flight, a general increase in asymmetry of otolith responses was observed on landing day relative to pre-flight baseline, with a subsequent reversal in asymmetry within 2-3 days. Recovery to baseline levels was achieved within 10 days. This fluctuation in the asymmetry measures appeared strongest for SVV, in a consistent direction for OOR, and in an opposite direction for cVEMP. These results are consistent with our hypothesis that space flight results in adaptive changes in central nervous system processing of otolith input. Adaptation to microgravity may reveal asymmetries in otolith function upon to return to Earth that were not detected prior to the flight due to compensatory mechanisms

A comparison of two gluteus maximus EMG maximum voluntary isometric contraction positions

Background. The purpose of this study was to compare the peak electromyography (EMG) of the most commonly-used position in the literature, the prone bent-leg (90°) hip extension against manual resistance applied to the distal thigh (PRONE), to a novel position, the standing glute squeeze (SQUEEZE). Methods. Surface EMG electrodes were placed on the upper and lower gluteus maximus of thirteen recreationally active females (age = 28.9 years; height = 164 cm; body mass = 58.2 kg), before three maximum voluntary isometric contraction (MVIC) trials for each position were obtained in a randomized, counterbalanced fashion. Results. No statistically significant (p \u3c 0.05) differences were observed between PRONE (upper: 91.94%; lower: 94.52%) and SQUEEZE (upper: 92.04%; lower: 85.12%) for both the upper and lower gluteus maximus. Neither the PRONE nor SQUEEZE was more effective between all subjects. Conclusions. In agreement with other studies, no single testing position is ideal for every participant. Therefore, it is recommended that investigators employ multiple MVIC positions, when possible, to ensure accuracy. Future research should investigate a variety of gluteus maximus MVIC positions in heterogeneous samples

Beyond deficit-based models of learners' cognition: Interpreting engineering students' difficulties with sense-making in terms of fine-grained epistemological and conceptual dynamics

Researchers have argued against deficit-based explanations of students' troubles with mathematical sense-making, pointing instead to factors such as epistemology: students' beliefs about knowledge and learning can hinder them from activating and integrating productive knowledge they have. In this case study of an engineering major solving problems (about content from his introductory physics course) during a clinical interview, we show that "Jim" has all the mathematical and conceptual knowledge he would need to solve a hydrostatic pressure problem that we posed to him. But he reaches and sticks with an incorrect answer that violates common sense. We argue that his lack of mathematical sense-making-specifically, translating and reconciling between mathematical and everyday/common-sense reasoning-stems in part from his epistemological views, i.e., his views about the nature of knowledge and learning. He regards mathematical equations as much more trustworthy than everyday reasoning, and he does not view mathematical equations as expressing meaning that tractably connects to common sense. For these reasons, he does not view reconciling between common sense and mathematical formalism as either necessary or plausible to accomplish. We, however, avoid a potential "deficit trap"-substituting an epistemological deficit for a concepts/skills deficit-by incorporating multiple, context-dependent epistemological stances into Jim's cognitive dynamics. We argue that Jim's epistemological stance contains productive seeds that instructors could build upon to support Jim's mathematical sense-making: He does see common-sense as connected to formalism (though not always tractably so) and in some circumstances this connection is both salient and valued.Comment: Submitted to the Journal of Engineering Educatio

Methods matter: the relationship between strength and hypertrophy depends on methods of measurement and analysis

Purpose: The relationship between changes in muscle size and strength may be affected by both measurement and statistical approaches, but their effects have not been fully considered or quantified. Therefore, the purpose of this investigation was to explore how different methods of measurement and analysis can affect inferences surrounding the relationship between hypertrophy and strength gain. Methods: Data from a previous study—in which participants performed eight weeks of elbow flexor training, followed by an eight-week period of detraining—were reanalyzed using different statistical models, including standard between-subject correlations, analysis of covariance, and hierarchical linear modeling. Results: The associative relationship between strength and hypertrophy is highly dependent upon both method/site of measurement and analysis; large differences in variance accounted for (VAF) by the statistical models were observed (VAF = 0– 24.1%). Different sites and measurements of muscle size showed a range of correlations coefficients with one another (r = 0.326–0.945). Finally, exploratory analyses revealed moderate-to-strong relationships between within-individual strength-hypertrophy relationships and strength gained over the training period (ρ = 0.36–0.55). Conclusions: Methods of measurement and analysis greatly influence the conclusions that may be drawn from a given dataset. Analyses that do not account for inter- individual differences may underestimate the relationship between hypertrophy and strength gain, and different methods of assessing muscle size will produce different results. It is suggested that robust experimental designs and analysis techniques, which control for different mechanistic sources of strength gain and inter-individual differences (e.g., muscle moment arms, muscle architecture, activation, and normalized muscle force), be employed in future investigations

Hospital-skilled nursing facility referral linkage reduces readmission rates among Medicare patients receiving major surgery

BACKGROUND: In the health reform era, rehospitalization following discharge may result in financial penalties to hospitals. The effect of increased hospital-skilled nursing facility (SNF) linkage on readmission reduction following surgery has not been explored. METHODS: To determine whether enhanced hospital-SNF linkage, as measured by the proportion of surgical patients referred from a hospital to a particular SNF, would result in reduced 30-day readmission rates for surgical patients, we used national Medicare data (2011-12) and evaluated patients who received one of five surgical procedures (coronary artery bypass grafting, hip fracture repair, total hip arthroplasty, colectomy, lumbar spine surgery). Initial evaluation was performed using regression modeling. Patient choice in SNF referral was adjusted for using instrumental variable (IV) analysis with distance between an individuals’ home and the SNF as the IV. RESULTS: A strong negative correlation (p<0.001) was observed between the proportion of selected surgical discharges received by a SNF and the rate of hospital readmission. Increasing the proportion of surgical discharges decreased the likelihood of rehospitalization (RC −0.04, 95% CI [−0.07, −0.02]). These findings were preserved in IV analysis. Increasing hospital-SNF linkage was found to significantly reduce the likelihood of readmission for patients receiving lumbar spine surgery, CABG and hip fracture repair. CONCLUSIONS: The benefits of increased hospital-SNF linkage appear to include meaningful reductions in hospital readmission following surgery. Overall, a 10% increase in the proportion of surgical referrals to a particular SNF is estimated to reduce readmissions by 4%. This may impact hospital-SNF networks participating in risk-based reimbursement models

A Critical Evaluation of the Biological Construct Skeletal Muscle Hypertrophy: Size Matters but So Does the Measurement

Skeletal muscle is highly adaptable and has consistently been shown to morphologically respond to exercise training. Skeletal muscle growth during periods of resistance training has traditionally been referred to as skeletal muscle hypertrophy, and this manifests as increases in muscle mass, muscle thickness, muscle area, muscle volume, and muscle fiber cross-sectional area (fCSA). Delicate electron microscopy and biochemical techniques have also been used to demonstrate that resistance exercise promotes ultrastructural adaptations within muscle fibers. Decades of research in this area of exercise physiology have promulgated a widespread hypothetical model of training-induced skeletal muscle hypertrophy; specifically, fCSA increases are accompanied by proportional increases in myofibrillar protein, leading to an expansion in the number of sarcomeres in parallel and/or an increase in myofibril number. However, there is ample evidence to suggest that myofibrillar protein concentration may be diluted through sarcoplasmic expansion as fCSA increases occur. Furthermore, and perhaps more problematic, are numerous investigations reporting that pre-to-post training change scores in macroscopic, microscopic, and molecular variables supporting this model are often poorly associated with one another. The current review first provides a brief description of skeletal muscle composition and structure. We then provide a historical overview of muscle hypertrophy assessment. Next, current-day methods commonly used to assess skeletal muscle hypertrophy at the biochemical, ultramicroscopic, microscopic, macroscopic, and whole-body levels in response to training are examined. Data from our laboratory, and others, demonstrating correlations (or the lack thereof) between these variables are also presented, and reasons for comparative discrepancies are discussed with particular attention directed to studies reporting ultrastructural and muscle protein concentration alterations. Finally, we critically evaluate the biological construct of skeletal muscle hypertrophy, propose potential operational definitions, and provide suggestions for consideration in hopes of guiding future research in this area

A Critical Evaluation of the Biological Construct Skeletal Muscle Hypertrophy: Size Matters but So Does the Measurement

Skeletal muscle is highly adaptable and has consistently been shown to morphologically respond to exercise training. Skeletal muscle growth during periods of resistance training has traditionally been referred to as skeletal muscle hypertrophy, and this manifests as increases in muscle mass, muscle thickness, muscle area, muscle volume, and muscle fiber cross-sectional area (fCSA). Delicate electron microscopy and biochemical techniques have also been used to demonstrate that resistance exercise promotes ultrastructural adaptations within muscle fibers. Decades of research in this area of exercise physiology have promulgated a widespread hypothetical model of training-induced skeletal muscle hypertrophy; specifically, fCSA increases are accompanied by proportional increases in myofibrillar protein, leading to an expansion in the number of sarcomeres in parallel and/or an increase in myofibril number. However, there is ample evidence to suggest that myofibrillar protein concentration may be diluted through sarcoplasmic expansion as fCSA increases occur. Furthermore, and perhaps more problematic, are numerous investigations reporting that pre-to-post training change scores in macroscopic, microscopic, and molecular variables supporting this model are often poorly associated with one another. The current review first provides a brief description of skeletal muscle composition and structure. We then provide a historical overview of muscle hypertrophy assessment. Next, current-day methods commonly used to assess skeletal muscle hypertrophy at the biochemical, ultramicroscopic, microscopic, macroscopic, and whole-body levels in response to training are examined. Data from our laboratory, and others, demonstrating correlations (or the lack thereof) between these variables are also presented, and reasons for comparative discrepancies are discussed with particular attention directed to studies reporting ultrastructural and muscle protein concentration alterations. Finally, we critically evaluate the biological construct of skeletal muscle hypertrophy, propose potential operational definitions, and provide suggestions for consideration in hopes of guiding future research in this area

A Comparison of Increases in Volume Load Over 8 Weeks of Low-Versus High-Load Resistance Training

Background: It has been hypothesized that the ability to increase volume load (VL) via a progressive increase in the magnitude of load for a given exercise within a given repetition range could enhance the adaptive response to resistance training. Objectives: The purpose of this study was to compare changes in volume load (VL) over eight weeks of resistance training (RT) in high-versus low-load protocols. Materials and Methods: Eighteen well-trained men were matched according to baseline strength were randomly assigned to either a low-load RT(LOW,n= 9) where 25 - 35 repetitions were performed per exercise, or a high-load RT (HIGH,n= 9) where 8 - 12 repetitions were performed per exercise. Both groups performed three sets of seven exercises for all major muscles three times per week on nonconsecutive days. Results: After adjusting for the pre-test scores, there was a significant difference between the two intervention groups on post intervention total VL with a very large effect size (F (1, 15) = 16.598, P = .001, p2 = .525). There was a significant relationship between pre-intervention and post-intervention total VL (F (1, 15) = 32.048, P \u3c .0001, p2 = .681) in which the pre-test scores explained 68% of the variance in the post-test scores. Conclusions: This study indicates that low-load RT results in greater accumulations in VL compared to high-load RT over the course of 8 weeks of training