Delphi survey on conventional conservative treatment of functional posterior shoulder instability

Background: Posterior shoulder instability is caused by structural or functional defects. While the former are mostly treated surgically, physiotherapy is considered the treatment of choice in functional shoulder instability. However, it often has limited success unless very specific and intensive training programs are applied by trained experts. Currently, there is no consensus on the treatment of functional posterior shoulder instability. Objective: To improve treatment of this pathology, a standardized treatment recommendation is required to serve as a guideline for physiotherapy. The aim of this study was to establish expert consensus for treatment recommendations for functional posterior shoulder instability. Design: The Delphi survey technique was employed. Methods: A standardized training program for treatment of functional posterior shoulder instability was developed by a local expert committee. Two rounds of an online Delphi survey were then conducted. The panel of the Delphi survey comprised nine leading scientific experts in the field of functional shoulder instability who treat patients with shoulder-related problems conservatively and operatively. Results: The response rate was 100% and there were no dropouts. The final program consists of three groups of exercises with increasing difficulty. The exercises are mostly easy to perform and focus on the scapula-retracting muscles and the muscles responsible for external rotation of the shoulder. The treatment program should be executed under the supervision of a therapist at the beginning and later may be performed by the patients themselves. Conclusion: Consensus on a new exercise guideline dedicated to the treatment of functional posterior shoulder instability was achieved. This guideline should not only help to treat this challenging pathology but also provide a starting point for further scientific research and ongoing improvement

MRI follow-up of subchondral signal abnormalities in a selected group of chronic low back pain patients

Subchondral signal abnormalities have been suggested to play an important role in chronic low back pain (LBP) syndromes. Their natural course is not well known. In this study the morphology and natural course of isolated subchondral signal abnormalities in the lumbosacral spine were analyzed with MRI. Twenty-four chronic LBP patients with a subchondral hypointensity on T1-weighted image (hyperintense on T2), indicating edema, were selected from a base population of 1,015 consecutive LBP patients to a follow-up MRI study within 18–72 months. Exclusion criteria were age >60 years, nerve root compression, a more specific back disease or a recent or major spine operation. The size and location of each subchondral signal abnormality and endplate lesion and the degree of degenerative disc changes were evaluated and compared between the baseline and follow-up studies. Most subchondral hypointensities were found at the L4/L5 or L5/S1 disc space, anteriorly and in both adjacent endplates. Almost all (53/54) hypointensities were associated with an endplate lesion. Twelve of the 54 subchondral hypointensities enlarged, six remained constant and 36 decreased or disappeared while five new ones appeared. Twenty-two (41%) hypointensities changed totally to hyperintensities or to mixed lesions. If the hypointensity increased, decreased or changed into hyperintensity, a change tended to develop in the adjacent endplate. If the hypointensity was absent or unchanged, endplate lesions did not tend to progress. In the absence of disc herniation or other specific spinal disease, subchondral hypointensities indicating edema are uncommon. They seem to have a highly variable course. There appears to be a link between endplate lesions and subchondral signal abnormalities. Further study is needed to explain the contribution of these findings to low back symptoms

Clinical perspectives on secular trends of intervertebral foramen diameters in an industrialized European society

Low back pain origins have been a matter of great controversy. While spinal stenosis is now radiologically traceable, the alteration of intervertebral foramen is less clear. The aim of this study was to assess "secular trends"-alterations occurring from one generation to the next-in osseous intervertebral foramina of the major vertebral segments in an industrialized society, and to discuss their possible clinical implication. The macerated "maximum intervertebral foramen width" and "intervertebral foramen height" of all major vertebral levels in 71 non-pathologic Swiss adult skeletons from the nineteenth and early twentieth century, with known individual age and sex and similar geographic and socio-economic background, were measured by sliding caliper at validated landmarks. A secular trend of the increase in "maximum intervertebral foramen width" is found for most levels, with females showing a more prominent alteration. Additionally, the non-pathologic "maximum intervertebral foramen width" does not change with respect to individual age, nor is a significant side difference detectable. "Intervertebral foramen height," hereby defined as the difference of the dorsal vertebral body height minus pedicle height, demonstrates for most levels, and either sex, an insignificant negative secular trend. Neither stature nor skeletal robustness vary significantly through time within this particular sample. The results of this study, despite obvious inadequacies of methods used, exclude secular narrowing of the "maximum intervertebral foramen width" as the only cause of radiculopathy or spinal stenosis. Furthermore, we found a mild insignificant decrease of the clinically more relevant "intervertebral foramen height." Nevertheless, the detected short-time variability of the bony intervertebral foramen, independent of individual stature, skeletal robustness or age, argues for an enhanced focus on the understanding of clinically relevant changes of spinal morphology from generation to generation

Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain

The prevalence of “vertebral endplate signal changes” (VESC) and its association with low back pain (LBP) varies greatly between studies. This wide range in reported prevalence rates and associations with LBP could be explained by differences in the definitions of VESC, LBP, or study sample. The objectives of this systematic critical review were to investigate the current literature in relation to the prevalence of VESC (including Modic changes) and the association with non-specific low back pain (LBP). The MEDLINE, EMBASE, and SveMED databases were searched for the period 1984 to November 2007. Included were the articles that reported the prevalence of VESC in non-LBP, general, working, and clinical populations. Included were also articles that investigated the association between VESC and LBP. Articles on specific LBP conditions were excluded. A checklist including items related to the research questions and overall quality of the articles was used for data collection and quality assessment. The reported prevalence rates were studied in relation to mean age, gender, study sample, year of publication, country of study, and quality score. To estimate the association between VESC and LBP, 2 × 2 tables were created to calculate the exact odds ratio (OR) with 95% confidence intervals. Eighty-two study samples from 77 original articles were identified and included in the analysis. The median of the reported prevalence rates for any type of VESC was 43% in patients with non-specific LBP and/or sciatica and 6% in non-clinical populations. The prevalence was positively associated with age and was negatively associated with the overall quality of the studies. A positive association between VESC and non-specific LBP was found in seven of ten studies from the general, working, and clinical populations with ORs from 2.0 to 19.9. This systematic review shows that VESC is a common MRI-finding in patients with non-specific LBP and is associated with pain. However, it should be noted that VESC may be present in individuals without LBP