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1.  Ipsilateral atrophy of paraspinal and psoas muscle in unilateral back pain patients with monosegmental degenerative disc disease 
The British Journal of Radiology  2011;84(1004):709-713.
The aim of this study was to assess the cross-sectional area (CSA) of both paraspinal and psoas muscles in patients with unilateral back pain using MRI and to correlate it with outcome measures.
40 patients, all with informed consent, with a minimum of 3 months of unilateral back pain with or without sciatica and one-level disc disease on MRI of the lumbosacral spine were included. Patients were evaluated with self-report measures regarding pain (visual analogue score) and disability (Oswestry disability index). The CSA of multifidus, erector spinae, quadratus lumborum and psoas was measured at the disc level of pathology and the two adjacent disc levels, bilaterally. Comparison of CSAs of muscles between the affected vs symptomless side was carried out with Student's t-test and correlations were conducted with Spearman's test.
The maximum relative muscle atrophy (% decrease in CSA on symptomatic side) independent of the level was 13.1% for multifidus, 21.8% for erector spinae, 24.8% for quadratus lumborum and 17.1% for psoas. There was significant difference (p<0.05) between sides (symptomatic and asymptomatic) in CSA of multifidus, erector spinae, quadratus lumborum and psoas. However, no statistically significant correlation was found between the duration of symptoms (average 15.5 months), patient's pain (average VAS 5.3) or disability (average ODI 25.2) and the relative muscle atrophy.
In patients with long-standing unilateral back pain due to monosegmental degenerative disc disease, selective multifidus, erector spinae, quadratus lumborum and psoas atrophy develops on the symptomatic side. Radiologists and clinicians should evaluate spinal muscle atrophy of patients with persistent unilateral back pain.
PMCID: PMC3473439  PMID: 21081573
2.  Changes of Paraspinal Muscles in Postmenopausal Osteoporotic Spinal Compression Fractures: Magnetic Resonance Imaging Study 
Journal of Bone Metabolism  2013;20(2):75-81.
To investigate the changes of cross sectional area (CSA) in paraspinal muscles upon magnetic resonance imaging (MRI) and bone mineral density (BMD) in postmenopausal osteoporotic spinal compression fractures.
We reviewed 81 postmenopausal women with osteoporosis, who had underwent MRI examination. The patients were divided into 51 patients who had osteoporotic spinal compression fractures (group I), and 30 patients who without fractures (group II). Group I were subdivided into IA and IB, based on whether they were younger (IA) of older (IB) than 70 years of age. We additionally measured body mass index and BMD. The CSA of multifidus, erector spinae, paraspinal muscles, psoas major (PT), and intervertebral (IV) discs were measured. The degree of fatty atrophy was estimated using three grades.
The BMD and T-score of group I were significantly lower than those of group II. The CSA of erector spinae, paraspinal muscles, and PT in the group I was significantly smaller than that of group II. The CSA of paraspinal muscles in group IB were significantly smaller than those of group IA. The CSA of erector spinae, mutifidus, and PT in group IB were smaller than those of group IA, but the difference was not statistically significant. Group 1 exhibited greater fat infiltration in the paraspinal muscle than group II.
Postmenopausal osteoporotic spinal compression fracture is associated with profound changes of the lumbar paraspinal muscle, reduction of CSA, increased CSA of IV disc, and increased intramuscular fat infiltration.
PMCID: PMC3910309  PMID: 24524061
Cross-sectional area; Fractures compression; Paraspinal muscles; Postmenopause
3.  Computed tomographic analysis of the quality of trunk muscles in asymptomatic and symptomatic lumbar discectomy patients 
No consensus exists on how rehabilitation programs for lumbar discectomy patients with persistent complaints after surgery should be composed. A better understanding of normal and abnormal postoperative trunk muscle condition might help direct the treatment goals.
A three-dimensional CT scan of the lumbar spine was obtained in 18 symptomatic and 18 asymptomatic patients who had undergone a lumbar discectomy 42 months to 83 months (median 63 months) previously. The psoas muscle (PS), the paraspinal muscle mass (PA) and the multifidus muscle (MF) were outlined at the L3, L4 and L5 level. Of these muscles, fat free Cross Sectional Area (CSA) and fat CSA were determined. CSA of the lumbar erector spinae (LES = longissimus thoracis + iliocostalis lumborum) was calculated by subtracting MF CSA from PA CSA. Mean muscle CSA of the left and right sides was calculated at each level. To normalize the data for interpersonal comparison, the mean CSA was divided by the CSA of the L3 vertebral body (mCSA = normalized fat-free muscle CSA; fCSA = normalized fat CSA). Differences in CSA between the pain group and the pain free group were examined using a General Linear Model (GLM). Three levels were examined to investigate the possible role of the level of operation.
In lumbar discectomy patients with pain, the mCSA of the MF was significantly smaller than in pain-free subjects (p = 0.009) independently of the level. The mCSA of the LES was significantly smaller in pain patients, but only on the L3 slice (p = 0.018). No significant difference in mCSA of the PS was found between pain patients and pain-free patients (p = 0.462). The fCSA of the MF (p = 0.186) and of the LES (p = 0.256) were not significantly different between both populations. However, the fCSA of the PS was significantly larger in pain patients than in pain-free patients. (p = 0.012).
The level of operation was never a significant factor.
CT comparison of MF, LES and PS muscle condition between lumbar discectomy patients without pain and patients with protracted postoperative pain showed a smaller fat-free muscle CSA of the MF at all levels examined, a smaller fat- free muscle CSA of the LES at the L3 level, and more fat in the PS in patients with pain. The level of operation was not found to be of importance. The present results suggest a general lumbar muscle dysfunction in the pain group, in particular of the deep stabilizing muscle system.
PMCID: PMC3079706  PMID: 21453531
4.  Fat infiltration in the lumbar multifidus and erector spinae muscles in subjects with sway-back posture 
European Spine Journal  2012;21(11):2158-2164.
Decreased activity of the lumbar stabilizer muscles has been identified in individuals with sway-back posture. Disuse can predispose these muscles to atrophy, which is characterized by a reduced cross-sectional area (CSA) and by fat infiltration. The aim of this study was to evaluate the amount of fat infiltration in the lumbar multifidus and lumbar erector spinae muscles as a sign of the muscle atrophy in individuals with sway-back posture, with and without low back pain.
Materials and methods
Forty-five sedentary individuals between 16 and 40 years old participated in this study. The sample was divided into three groups: symptomatic sway-back (SSBG) (n = 15), asymptomatic sway-back (ASBG) (n = 15), and control (CG) (n = 15). The individuals were first subjected to photographic analysis to classify their postures and were then referred for a magnetic resonance imaging (MRI) examination of the lumbar spine. The total (TCSA) and functional (FCSA) cross-sectional areas of the lumbar erector spinae together with lumbar multifidus and isolated lumbar multifidus muscles were measured from L1 to S1. The amount of fat infiltration was estimated as the difference between the TCSA and the FCSA.
Greater fat deposition was observed in the lumbar erector spinae and lumbar multifidus muscles of the individuals in the sway-back posture groups than in the control group. Pain may have contributed to the difference in the amount of fat observed in the groups with the same postural deviation. Similarly, sway-back posture may have contributed to the tissue substitution relative to the control group independently of low back pain.
The results of this study indicate that individuals with sway-back posture may be susceptible to morphological changes in their lumbar erector spinae and lumbar multifidus muscles, both due to the presence of pain and as a consequence of their habitual posture.
PMCID: PMC3481104  PMID: 22465969
Multifidus; Erector spinae; Magnetic resonance imaging; Posture; Sway-back
5.  The effects of rehabilitation on the muscles of the trunk following prolonged bed rest 
European Spine Journal  2010;20(5):808-818.
Microgravity and inactivity due to prolonged bed rest have been shown to result in atrophy of spinal extensor muscles such as the multifidus, and either no atrophy or hypertrophy of flexor muscles such as the abdominal group and psoas muscle. These effects are long-lasting after bed rest and the potential effects of rehabilitation are unknown. This two-group intervention study aimed to investigate the effects of two rehabilitation programs on the recovery of lumbo-pelvic musculature following prolonged bed rest. 24 subjects underwent 60 days of head down tilt bed rest as part of the 2nd Berlin BedRest Study (BBR2-2). After bed rest, they underwent one of two exercise programs, trunk flexor and general strength (TFS) training or specific motor control (SMC) training. Magnetic resonance imaging of the lumbo-pelvic region was conducted at the start and end of bed rest and during the recovery period (14 and 90 days after re-ambulation). Cross-sectional areas (CSAs) of the multifidus, psoas, lumbar erector spinae and quadratus lumborum muscles were measured from L1 to L5. Morphological changes including disc volume, spinal length, lordosis angle and disc height were also measured. Both exercise programs restored the multifidus muscle to pre-bed-rest size, but further increases in psoas muscle size were seen in the TFS group up to 14 days after bed rest. There was no significant difference in the number of low back pain reports for the two rehabilitation groups (p = .59). The TFS program resulted in greater decreases in disc volume and anterior disc height. The SMC training program may be preferable to TFS training after bed rest as it restored the CSA of the multifidus muscle without generating potentially harmful compressive forces through the spine.
PMCID: PMC3082685  PMID: 20593204
Bed rest; Magnetic resonance imaging; Gravity; Multifidus muscle; Psoas muscle; Rehabilitation
6.  An investigation into the use of MR imaging to determine the functional cross sectional area of lumbar paraspinal muscles 
European Spine Journal  2005;15(6):764-773.
The purpose of this study was to investigate the use of magnetic resonance (MR) imaging and image processing software to determine the functional cross-sectional area (FCSA) (the area of muscle isolated from fat) of the lumbar paraspinal muscles. The measurement of the morphology of the lumbar paraspinal muscles has become the focus of several recent investigations into the aetiology of low back pain. However, the reliability and validity of determining the FCSA of the lumbar paraspinal muscles using MR imaging are yet to be reported. T2 axial MR scans at the L1-S1 spinal levels of six subjects were obtained using identical MR systems and scanning parameters. Lean paraspinal muscle, vertebral body bone and intermuscular fat were manually segmented using image analysis software to assign a grey scale range to the MR signal intensity emitted by each tissue type. The resultant grey scale range for muscle was used to determine FCSA measurements for each of the paraspinal muscles, psoas, quadratus lumborum, erector spinae and lumbar multifidus on each scan slice. As various biological, instrument and measurement factors can affect MR signal intensity, a sensitivity analysis was conducted to determine the error associated in calculating FCSA for paraspinal muscle using a discrete grey scale range. Cross-sectional area and FCSA measurements were repeated three times and reliability indices for the FCSA measurements were obtained, showing excellent reliability, intra class correlation coefficient (mean=0.97, range 0.90–0.99) and %SEM (mean=2.6%, range 0.7–4.8%). In addition, the error associated with miscalculation of the grey scale range for the MR signal intensity of muscle was calculated and found to be low with an error of 20 grey scale units at the upper end of the muscle’s grey scale range resulting in a very small error in the measured muscle FCSA. The method presented in this paper has a variety of practical applications in areas such as evidence-based rehabilitation, biomechanical modelling and the determination of segmental inertial parameters.
PMCID: PMC3489434  PMID: 15895259
Lumbar spine; Magnetic resonance imaging; Cross sectional area; Low back pain; Muscle morphology
7.  CT imaging of trunk muscles in chronic low back pain patients and healthy control subjects 
European Spine Journal  2000;9(4):266-272.
Increasing documentation on the size and appearance of muscles in the lumbar spine of low back pain (LBP) patients is available in the literature. However, a comparative study between unoperated chronic low back pain (CLBP) patients and matched (age, gender, physical activity, height and weight) healthy controls with regard to muscle cross-sectional area (CSA) and the amount of fat deposits at different levels has never been undertaken. Moreover, since a recent focus in the physiotherapy management of patients with LBP has been the specific training of the stabilizing muscles, there is a need for quantifying and qualifying the multifidus. A comparative study between unoperated CLBP patients and matched control subjects was conducted. Twenty-three healthy volunteers and 32 patients were studied. The muscle and fat CSAs were derived from standard computed tomography (CT) images at three different levels, using computerized image analysis techniques. The muscles studied were: the total paraspinal muscle mass, the isolated multifidus and the psoas. The results showed that only the CSA of the multifidus and only at the lowest level (lower end-plate of L4) was found to be statistically smaller in LBP patients. As regards amount of fat, in none of the three studied muscles was a significant difference found between the two groups. An aetiological relationship between atrophy of the multifidus and the occurrence of LBP can not be ruled out as a possible explanation. Alternatively, atrophy may be the consequence of LBP: after the onset of pain and possible long-loop inhibition of the multifidus a combination of reflex inhibition and substitution patterns of the trunk muscles may work together and could cause a selective atrophy of the multifidus. Since this muscle is considered important for lumbar segmental stability, the phenomenon of atrophy may be a reason for the high recurrence rate of LBP.
PMCID: PMC3611341  PMID: 11261613
Key words Cross-sectional area; Fat deposits; Paravertebral muscles; Lumbar multifidus; Psoas
8.  Multifidus muscle changes and clinical effects of one-level posterior lumbar interbody fusion: minimally invasive procedure versus conventional open approach 
European Spine Journal  2009;19(2):316-324.
We set out to determine whether a minimally invasive approach for one-level instrumented posterior lumbar interbody fusion reduced undesirable changes in the multifidus muscle, compared to a conventional open approach. We also investigated associations between muscle injury during surgery (creatinine kinase levels), clinical outcome and changes in the multifidus at follow-up. We studied 59 patients treated by one team of surgeons at a single institution (minimally invasive approach in 28 and conventional open approach in 31, voluntarily chosen by patients). More than 1 year postoperatively, all the patients were followed up with the visual analogue scale (VAS) and Oswestry disability index (ODI), and 16 patients from each group were evaluated using MRI. This enabled the cross-sectional area (CSA) of lean multifidus muscle, and the T2 signal intensity ratio of multifidus to psoas muscle, to be compared at the operative and adjacent levels. The minimally invasive group had less postoperative back pain (P < 0.001) and lower postoperative ODI scores (P = 0.001). Multifidus atrophy was less in the minimally invasive group (P < 0.001), with mean reductions in CSA of 12.2% at the operative and 8.5% at the adjacent levels, compared to 36.8% and 29.3% in the conventional open group. The increase in the multifidus:psoas T2 signal intensity ratio was similarly less marked in the minimally invasive group where values increased by 10.6% at the operative and 8.3% at the adjacent levels, compared to 34.4 and 22.7% in the conventional open group (P < 0.001). These changes in multifidus CSA and T2 signal intensity ratio were significantly correlated with postoperative creatinine kinase levels, VAS scores and ODI scores (P < 0.01). The minimally invasive approach caused less change in multifidus, less postoperative back pain and functional disability than conventional open approach. Muscle damage during surgery was significantly correlated with long-term multifidus muscle atrophy and fatty infiltration. Furthermore these degenerative changes of multifidus were also significantly correlated with long-term clinical outcome.
PMCID: PMC2899808  PMID: 19876659
Minimally invasive; Lumbar spine; Multifidus muscle; Interbody fusion
9.  Changes in the Cross-Sectional Area of Multifidus and Psoas in Unilateral Sciatica Caused by Lumbar Disc Herniation 
To quantitatively evaluate the asymmetry of the multifidus and psoas muscles in unilateral sciatica caused by lumbar disc herniation using magnetic resonance imaging (MRI).
Seventy-six patients who underwent open microdiscectomy for unilateral L5 radiculopathy caused by disc herniation at the L4-5 level were enrolled, of which 39 patients (51.3%) had a symptom duration of 1 month or less (group A), and 37 (48.7%) had a symptom duration of 3 months or more (group B). The cross-sectional areas (CSAs) of the multifidus and psoas muscles were measured at the mid-portion of the L4-5 disc level on axial MRI, and compared between the diseased and normal sides in each group.
The mean symptom duration was 0.6±0.4 months and 5.4±2.7 months for groups A and B, respectively (p<0.001). There were no differences in the demographics between the 2 groups. There was a significant difference in the CSA of the multifidus muscle between the diseased and normal sides (p<0.01) in group B. In contrast, no significant multifidus muscle asymmetry was found in group A. The CSA of the psoas muscle was not affected by disc herniation in either group.
The CSA of the multifidus muscle was reduced by lumbar disc herniation when symptom duration was 3 months or more.
PMCID: PMC3218178  PMID: 22102949
Multifidus; Psoas; Cross-sectional area; Lumbar disc herniation
10.  MRI features of the psoas major muscle in patients with low back pain 
European Spine Journal  2013;22(9):1965-1971.
The purpose was to investigate the changes of the psoas major muscles (PM) cross-sectional area (CSA) and fat infiltration in the PM and to investigate the association between the morphology of the PM and expression of the degenerative changes of lumbar spine in patients with low back pain (LBP).
T2-weighted scans for measurements of the CSA and analysis of fat infiltration were performed on 42 patients and 49 controls using a 1.5 Tesla MR system. For a quantitative analysis of fat tissue infiltration a 4-grade visual scale was used.
Patients had bigger CSA of the PM than controls at the levels of L3/L4 and L4/L5 intervertebral disc (P < 0.05). Patients with apparent degenerative changes of the lumbar spine had smaller CSA of the PM compared to the patients without apparent changes at the levels of L3/L4 and L4/L5 (P < 0.05). At the levels of L4/L5 and L5/S1 patients with present Modic changes in the lumbar vertebral bodies showed smaller CSA of the PM compared to the patients without Modic changes (P < 0.05). However, CSA of the PM in the patients with degenerative changes of lumbar spine and Modic changes was still bigger than the one of the controls. At all analyzed levels correlation between CSAs of the PM and fat infiltration of the lumbar paraspinal muscles was negative.
Results suggest increased activity of the PM in LBP patients but PM also remains active regardless of the presence of degenerative and Modic changes of the lumbar spine.
PMCID: PMC3777059  PMID: 23543369
Psoas major muscle; Low back pain; MRI; Disc degeneration; Modic changes
11.  Magnitude of spinal muscle damage is not statistically associated with exercise-induced low back pain intensity 
Findings on imaging of noncontractile anatomic abnormalities and the intensity of low back pain have weak associations because of false-positive rates among asymptomatic individuals. This association might be stronger for contractile tissues.
The purpose of this study was to examine the relationship between location and reports of pain intensity in the low back and exercise-induced muscle damage to the lumbar paraspinal muscles.
Nondiagnostic observational study in a laboratory setting.
Delayed onset muscle soreness was induced in the low back of healthy pain-free volunteers. Measures of pain intensity (100-mm visual analog scale [VAS]) and location (area on the pain diagram) were taken before and 48 hours after exercise. Muscle damage was quantified using mechanical pain thresholds, motor performance deficits, and transverse relaxation time (T2)–weighted magnetic resonance imaging (MRI). Changes pre- to postexercise in signal intensity on T2-weighted imaging within the erector spinae, pain intensity, pain area, mechanical pain threshold, and isometric torque were assessed using paired t tests. Bivariate correlations were conducted to assess associations among muscle damage, pain intensity, and pain drawing area.
Twenty participants volunteered (11 women; average age, 22.3 years; average body mass index, 23.5) for study participation. Reports of pain intensity at 48 hours ranged from 0 to 59 mm on the VAS. Muscle damage was confirmed by reductions in mechanical threshold (p=.011) and motor performance (p<.001) and by changes in T2-weighted MRI (p=.007). This study was powered to find an association of at least r=0.5 to be statistically significant. Correlations of continuous variables revealed no significant correlations between pain intensity and measures of muscle damage (ranging between −0.075 and 0.151). There was a significant association between the remaining torque deficit at 48 hours and pain area.
The results of this study indicate that there was no association between the magnitude of muscle damage in the lumbar erector spinae and reported pain intensity in the low back. In future studies, larger cohorts may report statistically significant associations, but our data suggest that there will be low magnitude potentially indicating limited clinical relevance.
PMCID: PMC3437659  PMID: 22208857
Spinal disorders; Imaging; Referred pain
12.  Assessment of neuromuscular and haemodynamic activity in individuals with and without chronic low back pain 
Dynamic Medicine  2006;5:6.
Biering-Sørenson (1984) found that individuals with less lumbar extensor muscle endurance had an increased occurrence of first episode low back pain. As a result, back endurance tests have been recommended for inclusion in health assessment protocols. However, different studies have reported markedly different values for endurance times, leading some researchers to believe that the back is receiving support from the biceps femoris and gluteus maximus. Therefore, this study was designed to examine the haemodynamic and neuromuscular activity of the erector spinae, biceps femoris, and gluteus maximus musculature during the Biering-Sørenson Muscular Endurance Test (BSME).
Seventeen healthy individuals and 46 individuals with chronic low back pain performed the Biering-Sørenson Muscular Endurance Test while surface electromyography was used to quantify neuromuscular activity. Disposable silver-silver-chloride electrodes were placed in a bipolar arrangement over the right or left biceps femoris, gluteus maximus, and the lumbosacral paraspinal muscles at the level of L3. Near Infrared Spectroscopy was used simultaneously to measure tissue oxygenation and blood volume changes of the erector spinae and biceps femoris.
The healthy group displayed a significantly longer time to fatigue (Healthy: 168.5s, LBP: 111.1s; p ≤ 0.05). Significant differences were shown in the median frequency slope of the erector spinae between the two groups at 90–100% of the time to fatigue while no significant differences were noted in the haemodynamic data for the two groups.
Although the BSME has been recognized as a test for back endurance, individuals with chronic LBP appear to incorporate a strategy that may help support the back musculature by utilizing the biceps femoris and gluteus maximus to a greater degree than their healthy counterparts.
PMCID: PMC1489922  PMID: 16734915
13.  The Relationship between Cross Sectional Area and Strength of Back Muscles in Patients with Chronic Low Back Pain 
Annals of Rehabilitation Medicine  2012;36(2):173-181.
To evaluate the relationship between the cross sectional area (CSA) and isokinetic strength of the back muscles in patients with chronic low back pain.
Data of twenty-eight middle-aged patients with chronic back pain were analyzed retrospectively. CSAs of both paraspinal muscles and the disc at the L4-L5 level were measured in MRI axial images and the relative CSAs (rCSA: CSA ratio of muscle and disc) were calculated. The degree of paraspinal muscle atrophy was rated qualitatively. Isokinetic strengths (peak torque, peak torque per body weight) of back flexor and extensor were measured with the isokinetic testing machine. Multiple regression analysis with backward elimination was used to evaluate relations between isokinetic strength and various factors, such as CSA or rCSA and clinical characteristics in all patients. The same analysis was repeated in the female patients.
In analysis with CSA and clinical characteristics, body mass index (BMI) and CSA were significant influencing factors in the peak torque of the back flexor muscles. CSA was a significant influencing factor in the peak torque of total back muscles. In analysis with rCSA and clinical characteristics, BMI was significant in influencing the peak torque of the back flexors. In female patients, rCSA was a significant influencing factor in the peak torque per body weight of the back flexors, and age and BMI were influencing factors in the peak torque of back flexors and total back muscles.
In middle-aged patients with chronic low back pain, CSA and rCSA were influencing factors in the strength of total back muscles and back flexors. Also, gender and BMI were influencing factors.
PMCID: PMC3358672  PMID: 22639740
Low back pain; Muscle strength; Muscle strength dynamometer; Magnetic resonance imaging
14.  Changes in paraspinal muscles and their association with low back pain and spinal degeneration: CT study 
European Spine Journal  2009;19(7):1136-1144.
The objectives of the study were to evaluate the association between lumbar paraspinal muscle density, evaluated on computed tomography (CT) and age, sex and BMI; and to evaluate the association of those changes with low back pain (LBP) and spinal degeneration features in a community-based sample. This study was an ancillary project to the Framingham Study. A sample of 3,529 participants aged 40–80 years had a CT scan performed to assess aortic calcification. 187 individuals were randomly enrolled in this study. LBP in the last 12 months was evaluated using self-report questionnaire. Density (in Hounsfield units) of multifidus and erector spinae was evaluated on CT. The prevalence of intervertebral disc narrowing, facet joint osteoarthritis (FJOA), spondylolysis, spondylolisthesis and spinal stenosis were also evaluated. We used linear regression models to examine the association of paraspinal muscles density with age, sex, BMI, LBP, and spinal degeneration features. The results show that in our study, men have higher density of paraspinal muscles than women, younger individuals have higher density than older ones and individuals with lower weight have higher muscle density than overweight. No differences between individuals with and without LBP were found. Significant association was found between L4 multifidus/erector spinae density and FJOA at L4–L5; between multifidus at L4 and spondylolisthesis at L4–5; and between erector spinae at L4 and L5 with disc narrowing at L4–5 and L5–S1, respectively. We conclude that the paraspinal muscle density decreases with age, and increases BMI. It is associated with at some levels FJOA, spondylolisthesis and disc narrowing at the same level, but not associated with occurrence of LBP.
PMCID: PMC2900015  PMID: 20033739
Low back pain; Paraspinal muscles; Multifidus; Erector spinae; Computed tomography
15.  Effects of three different training modalities on the cross sectional area of the lumbar multifidus muscle in patients with chronic low back pain 
Objectives—To determine the effect of different training schedules on the cross sectional area (CSA) of the lumbar multifidus muscle in patients with chronic low back pain.
Methods—Each of 59 nine patients was randomly assigned to one of three programmes: 10 weeks of stabilisation training (group 1; n = 19); 10 weeks of stabilisation training combined with dynamic resistance training (group 2; n = 20); 10 weeks of stabilisation training combined with dynamic-static resistance training (group 3; n = 20). Before and after 10 weeks of training, multifidus CSAs were measured from standard computed tomography images at three different levels (upper end plate of L3 and L4, and lower end plate of L4).
Results—The CSA of the multifidus muscle was significantly increased at all levels after training in group 3. In contrast, no significant differences were found in groups 1 and 2.
Conclusions—General stabilisation exercises and dynamic intensive lumbar resistance training have no significant effect on the CSA of the lumbar multifidus muscle in patients with chronic low back pain. The static holding component between the concentric and eccentric phase was found to be critical in inducing muscle hypertrophy during the first 10 weeks. Treatment consisting of stabilisation training combined with an intensive lumbar dynamic-static strengthening programme seems to be the most appropriate method of restoring the size of the multifidus muscle.
Key Words: back pain; multifidus muscle; stabilisation; dynamic; dynamic-static; hypertrophy
PMCID: PMC1724339  PMID: 11375879
16.  Does minimally invasive lumbar disc surgery result in less muscle injury than conventional surgery? A randomized controlled trial 
European Spine Journal  2010;20(1):51-57.
The concept of minimally invasive lumbar disc surgery comprises reduced muscle injury. The aim of this study was to evaluate creatine phosphokinase (CPK) in serum and the cross-sectional area (CSA) of the multifidus muscle on magnetic resonance imaging as indicators of muscle injury. We present the results of a double-blind randomized trial on patients with lumbar disc herniation, in which tubular discectomy and conventional microdiscectomy were compared. In 216 patients, CPK was measured before surgery and at day 1 after surgery. In 140 patients, the CSA of the multifidus muscle was measured at the affected disc level before surgery and at 1 year after surgery. The ratios (i.e. post surgery/pre surgery) of CPK and CSA were used as outcome measures. The multifidus atrophy was classified into three grades ranging from 0 (normal) to 3 (severe atrophy), and the difference between post and pre surgery was used as an outcome. Patients’ low-back pain scores on the visual analogue scale (VAS) were documented before surgery and at various moments during follow-up. Tubular discectomy compared with conventional microdiscectomy resulted in a nonsignificant difference in CPK ratio, although the CSA ratio was significantly lower in tubular discectomy. At 1 year, there was no difference in atrophy grade between both groups nor in the percentage of patients showing an increased atrophy grade (14% tubular vs. 18% conventional). The postoperative low-back pain scores on the VAS improved in both groups, although the 1-year between-group mean difference of improvement was 3.5 mm (95% CI; 1.4–5.7 mm) in favour of conventional microdiscectomy. In conclusion, tubular discectomy compared with conventional microdiscectomy did not result in reduced muscle injury. Postoperative evaluation of CPK and the multifidus muscle showed similar results in both groups, although patients who underwent tubular discectomy reported more low-back pain during the first year after surgery.
PMCID: PMC3036021  PMID: 20556439
Creatine phosphokinase; Muscle injury; Atrophy; Microdiscectomy; Herniated disc; Low-back pain
17.  EMG analysis of lumbar paraspinal muscles as a predictor of the risk of low-back pain 
European Spine Journal  2010;19(7):1145-1152.
Studies of EMG power spectra have established associations between low-back pain (LBP) and median frequency (MF). This 2-year prospective study investigates the association of LBP with EMG variables over time. 120 health care workers underwent paraspinal EMG measurements and assessment of back pain disability. The EMG recordings were performed under isometric trunk extension at 2/3 maximum voluntary contraction and acquired from erector spinae muscles at the level of L4/L5. 108 (90%) subjects were reviewed at a minimum 2-year follow up. 16 out of 93 subjects with no history of chronic low-back pain became worse as measured by time off work, disability, reported pain and self-assessment rating. The value of the EMG variable half-width at inception demonstrated significant association with changes in subject’s outcome measure and their own assessment of their LBP at follow up (p < 0.05). Based on self-assessment data, subjects with no history of chronic LBP with half-width of greater than 56 Hz were at threefold greater risk of developing back pain compared with the remainder of the population (p = 0.045). The value of the initial median frequency (IMF) and MF slope at inception were also associated with the subjects’ own assessment of LBP at follow up. Subjects with an IMF greater than 49 Hz were at 5.8-fold greater risk of developing back pain compared with the remainder of the population (p = 0.014). EMG variables recorded from lumbar paraspinal muscles can identify a sub group of subjects at increased risk of developing low-back pain in the future.
PMCID: PMC2900021  PMID: 20127260
EMG; Low back pain; Paraspinal muscles; Prediction; Cohort study
18.  Effects of Spinal Stabilization Exercise on the Cross-sectional Areas of the Lumbar Multifidus and Psoas Major Muscles, Pain Intensity, and Lumbar Muscle Strength of Patients with Degenerative Disc Disease 
[Purpose] The aim of this study was to evaluate the efficacy of using spinal stabilizing exercise to reduce atrophy of the multifidus and psoas major muscles, reduce the levels of pain and disability, and increase paraspinal muscle strength in patients with degenerative disc disease (DDD). [Subjects and Methods] In 33 patients (Age range: 25–65 years) diagnosed with DDD, spinal stabilization exercise was conducted for 8 weeks. The levels of pain and disability were measured before and after exercise using the visual analogue scale (VAS) and the Oswestry Disability Index (ODI). Paraspinal muscular strength in four directions was evaluated with a CENTAUR 3D Spatial Rotation Device. Cross-sectional areas (CSAs) of both the left and right multifidus and the psoas major at the upper endplate of L4 were measured before and after exercise using computed tomography (CT). [Results] After 8 weeks of spinal stabilization exercise, the pain and lumbar disability in subjects decreased significantly from 6.12±1.24 to 2.43±1.14. The ODI score also improved from 20.18±7.14 to 8.81±5.73. In addition, paraspinal muscle strength increased significantly, while the CSAs of the left and right multifidus and psoas major widened as compared with the pre-exercise size. [Conclusion] Spinal stabilization exercise was effective for reducing pain and disability in DDD patients. It was an effective adjunct to aid rehabilitation in these cases.
PMCID: PMC3996425  PMID: 24764637
Degenerative disc disease; Spinal stabilization; Multifidus
19.  Muscle Imbalance Among Elite Australian Rules Football Players: A Longitudinal Study of Changes in Trunk Muscle Size 
Journal of Athletic Training  2012;47(3):314-319.
Trunk muscles, such as the transversus abdominis (TrA) and multifidus, play a key role in lumbopelvic stability, which is important in athletic performance. Asymmetry or imbalance in these and other trunk muscles could result from the specific requirements of the game of Australian rules football.
To determine whether seasonal variations in the sizes of key trunk muscles associated with lumbopelvic stability occur in Australian Football League players.
Cross-sectional study.
Patients or Other Participants:
The number of players eligible to participate at each of the 4 time points was 36 at the start of preseason 1 (T1), 31 at end of season 1 (T2), 43 at the end of preseason 2 (T3), and 41 at the start of preseason 3 (T4). The group with data at all 4 time points (n  =  20) was used in the analyses and was shown to be representative of the total sample.
Magnetic resonance imaging was used to determine the cross-sectional areas (CSAs) of the multifidus (vertebral levels L2 to L5) and lumbar erector spinae (LES) muscles (L3), as well as the thickness of the TrA and internal oblique (IO) muscles at L3.
Main Outcome Measure(s):
Cross-sectional areas of the multifidus and LES muscles and thickness of the TrA and IO muscles.
By the end of the playing season, results showed 11.1% atrophy for multifidus CSA at L3 and 21% atrophy for TrA thickness at rest. In comparison, the CSA of the LES muscles increased by 3.6%, and the thickness of the IO muscle increased by 11.8% compared with the start of the preseason.
The results indicated an imbalance of the key muscles associated with lumbopelvic stability.
PMCID: PMC3392162  PMID: 22892413
Australian Football League; magnetic resonance imaging; multifidus muscle; transversus abdominis muscle
20.  Facilitating Effects of Fast and Slope Walking on Paraspinal Muscles 
Annals of Rehabilitation Medicine  2014;38(4):514-522.
To quantify the activation of the paraspinalis muscles (multifidus and erector spinae) at different walking velocities and slope with surface electromyography.
This study was a prospective experimental study involving ten healthy male participants. Surface electrodes were placed over the multifidus and erector spinae muscles at the L5 and L3 level. After the electrode was placed at the lumbar paraspinalis muscles, electromyography signals were recorded over 20 seconds. Data were collected three times during the walking exercise at a 0° gradient with the speed from 3 to 6 km/hr. At 7° gradient and 15° gradient, data were also collected three times but a walking speed of 4 km/hr. The area under the curve was calculated for quantitative measurement of muscle activation.
While the muscle activation was increased at higher walking velocities at the L5 and L3 levels of the multifidus, the erector spinae muscle activation did not show any change at higher walking velocities. At L3 level of the multifidus and erector spine muscles, the muscle activation was significantly increased in 15° gradient compared to those seen in at 0° gradient. At L5 level, the multifidus and erector spinae muscle activation in 0° gradient was not significantly different from that those seen in 7° or 15° gradient.
Fast walking exercise activates lumbar multifidus muscles more than the slow walking exercise. Also, the mid lumbar muscles are comparatively more activated than low lumbar muscles when the walking slope increases.
PMCID: PMC4163591  PMID: 25229030
Walking; Paraspinal muscles; Low back pain
21.  Muscle functional magnetic resonance imaging and acute low back pain: a pilot study to characterize lumbar muscle activity asymmetries and examine the effects of osteopathic manipulative treatment 
Muscle functional magnetic resonance imaging (mfMRI) measures transverse relaxation time (T2), and allows for determination of the spatial pattern of muscle activation. The purposes of this pilot study were to examine whether MRI-derived T2 or side-to-side differences in T2 (asymmetries) differ in low back muscles between subjects with acute low back pain (LBP) compared to asymptomatic controls, and to determine if a single osteopathic manipulative treatment (OMT) session alters these T2 properties immediately and 48-hours after treatment.
Subjects with non-specific acute LBP (mean score on 1-10 visual analog score = 3.02 ± 2.81) and asymptomatic controls (n = 9/group) underwent an MRI, and subsequently the LBP subjects received OMT and then underwent another MRI. The LBP subjects reported back for an additional MRI 48-hours following their initial visit. T2 and T2 asymmetry were calculated from regions of interest for the psoas, quadratus lumborum (QL), multifidus, and iliocostalis lumborum/longissimus thoracis (IL/LT) muscles.
No differences were observed between the groups when T2 was averaged for the left and right side muscles. However, the QL displayed a significantly greater T2 asymmetry in LBP subjects when compared to controls (29.1 ± 4.3 vs. 15.9 ± 4.1%; p = 0.05). The psoas muscle also displayed a relatively large, albeit non-significant, mean difference (22.7 ± 6.9 vs. 9.5 ± 2.8%; p = 0.11). In the subjects with LBP, psoas T2 asymmetry was significantly reduced immediately following OMT (25.3 ± 6.9 to 6.1 ± 1.8%, p = 0.05), and the change in LBP immediately following OMT was correlated with the change in psoas T2 asymmetry (r = 0.75, p = 0.02).
Collectively, this pilot work demonstrates the feasibility of mfMRI for quantification and localization of muscle abnormalities in patients with acute low back pain. Additionally, this pilot work provides insight into the mechanistic actions of OMT during acute LBP, as it suggests that it may attenuate muscle activity asymmetries of some of the intrinsic low back muscles.
PMCID: PMC2744922  PMID: 19712459
22.  The Association of Nutritional Status and Gender with Cross-Sectional Area of the Multifidus Muscle in Establishing Normative Data 
Despite recognized evidence for the importance of the multifidus muscle in stabilizing the lumbar spine, identifying subjects at risk for injury and subsequent loss of intrinsic spinal stabilization remains difficult. Previous research has failed to associate multifidus muscle size and height, weight, or body mass index (BMI). The purpose of this study was to begin to establish normative data for the multifidus muscle cross-sectional area (CSA) at the L5 level and to identify factors associated with size. Twenty-five participants (17 female), with a mean age of 32.5 (SD 11.6) years without history of LBP were considered for inclusion. Participants' height and weight were recorded and BMI calculated. Ultrasound imaging was used to obtain a CSA in cm2 of the subjects' multifidus muscles at the L5 level bilaterally; testing was done by two trained testers. Prior to testing, intra- and inter-tester reliability were determined. Percent body fat was determined using a three-site skinfold caliper measurement, also using two trained testers. Mean BMI was 24.18 and mean body fat (%) was 22.88 for all participants. As expected, age and BMI were moderately correlated. Left and right multifidus muscle CSA were highly correlated (r = 0.92, p < 0.001). The mixed model ANOVA indicated a significant main effect for gender as males exhibited larger CSA than females. Participants without history of low back pain present with symmetrical multifidus muscle CSA at the L5 level. Clear gender differences in CSA show that males tend to have larger multifidus muscles at the L5 level, indicating a need to establish gender-specific norms for clinicians examining the L5 multifidus muscle.
PMCID: PMC2716158  PMID: 19771187
Lumbar Spine; Multifidus; Sonography
23.  Asymmetry of the cross-sectional area of paravertebral and psoas muscle in patients with degenerative scoliosis 
European Spine Journal  2013;22(6):1332-1338.
This study was undertaken to assess the change of psoas and paravertebral muscles in patients with degenerative scoliosis.
Eighty-five patients with degenerative scoliosis were evaluated with simple radiography for the location and direction of the apex of scoliosis, coronal Cobb’s angle, rotational deformity and lumbar lordosis, and with magnetic resonance imaging scan at the apex level of each patient, the cross-sectional area (CSA) and the fatty infiltration rate (FI) of bilateral paravertebral and psoas muscles were measured and the values of convex and concave side were compared.
Fifty-three patients had apex of curves on the left side and thirty-two patients on the right. The mean Cobb’s angle was 17.9°. The difference index of CSA (CDI) of psoas and multifidus muscle at apex of curvature level was significantly larger in convex side rather than that in concave side (by 6.3 and 8.4 % with P = 0.019 and 0.000, respectively). FI of each muscle showed no significant difference.
Hypertrophy of the muscles on the convex side is suggested as the explanation of this asymmetry rather than atrophy of the muscles on the concave side as muscle atrophy is known to be associated with increased fatty infiltration.
PMCID: PMC3676542  PMID: 23515711
Degenerative scoliosis; Psoas; Multifidus; Erector spinae; Paravertebral muscle; Cross-sectional area; Fatty degeneration
24.  Computed tomography–evaluated features of spinal degeneration: prevalence, intercorrelation, and association with self-reported low back pain 
Although the role of radiographic abnormalities in the etiology of nonspecific low back pain (LBP) is unclear, the frequent identification of these features on radiologic studies continues to influence medical decision making.
The primary purposes of the study were to evaluate the prevalence of lumbar spine degeneration features, evaluated on computed tomography (CT), in a community-based sample and to evaluate the association between lumbar spine degeneration features. The secondary purpose was to evaluate the association between spinal degeneration features and LBP.
This is a cross-sectional community-based study that was an ancillary project to the Framingham Heart Study.
A subset of 187 participants were chosen from the 3,529 participants enrolled in the Framingham Heart Study who underwent multidetector CT scan to assess aortic calcification.
Self-report measures: LBP in the preceding 12 months was evaluated using a Nordic self-report questionnaire. Physiologic measures: Dichotomous variables indicating the presence of intervertebral disc narrowing, facet joint osteoarthritis (OA), spondylolysis, spondylolisthesis, and spinal stenosis and the density (in Hounsfield units) of multifidus and erector spinae muscles were evaluated on CT.
We calculated the prevalence of spinal degeneration features and mean density of multifidus and erector spinae muscles in groups of individuals with and without LBP. Using the χ2 test for dichotomous and t test for continuous variables, we estimated the differences in spinal degeneration parameters between the aforementioned groups. To evaluate the association of spinal degeneration features with age, the prevalence of degeneration features was calculated in four age groups (less than 40, 40–50, 50–60, and 60+ years). We used multiple logistic regression models to examine the association between spinal degeneration features (before and after adjustment for age, sex, and body mass index [BMI]) and LBP, and between all degeneration features and LBP.
In total, 104 men and 83 women, with a mean age (±standard deviation) of 52.6±10.8 years, participated in the study. There was a high prevalence of intervertebral disc narrowing (63.9%), facet joint OA (64.5%), and spondylolysis (11.5%) in the studied sample. When all spinal degeneration features as well as age, sex, and BMI were factored in stepwise fashion into a multiple logistic regression model, only spinal stenosis showed statistically significant association with LBP, odds ratio (OR) (95% confidence interval [CI]): 3.45 [1.12–10.68]. Significant association was found between facet joint OA and low density of multifidus (OR [95% CI]: 3.68 [1.36–9.97]) and erector spinae (OR [95% CI]: 2.80 [1.10–7.16]) muscles.
Degenerative features of the lumbar spine were extremely prevalent in this community-based sample. The only degenerative feature associated with self-reported LBP was spinal stenosis. Other degenerative features appear to be unassociated with LBP.
PMCID: PMC3686273  PMID: 20006557
Low back pain; Computed tomography; Spine; Degeneration
25.  Treatment of chronic low back pain incorporating active patient participation and chiropractic: a retrospective case report 
Journal of Chiropractic Medicine  2005;4(4):200-205.
To present a retrospective case report about a patient who suffered from chronic lower back pain for sixteen years, finding little relief from numerous medical and traditional chiropractic interventions, until active patient participation was incorporated in the chiropractic treatment process.
Clinical Features
A 43-year-old female experienced severe right lumbar, right sacrum, and right acetabular pain and muscle spasms occurring after playing a vigorous tennis match 16 years earlier. Pain intensity was rated as 8 out of 10 on a variable analog scale. Prior treatments included prolonged bed rest, cortisone injection, chiropractic manipulation, stretching, acupuncture, physical therapy, and other rehabilitation interventions. By the time of presentation she also experienced right arm and right upper back pain. A lumbar MRI scan showed an L4/5 disc bulge. Patrick's, Yeoman's and Kemp's tests were positive on her right side. She had an asymmetrical gait pattern with a right hip hike, lateral shift and rotation of the pelvis. Weakness of the left gluteus maxi-mus, gluteus medius, and right erector spinae muscles was present. Motion palpation revealed several fixations. There was tenderness to palpation of the right psoas muscle and a trigger point in the right illiacus muscle.
Intervention and Outcome
Home-based rehabilitation including low-tech muscle-specific patient controlled dynamic spinal stabilization exercises, cardiovascular training and various stretching techniques was incorporated with chiropractic manipulation. Significant improvement was noted within a 40 week treatment course.
Incorporation of active patient participation seemed to be a significant factor in the resolution of the patient's low back pain. Active patient participation improved the quality of life for this patient.
PMCID: PMC2647049  PMID: 19674663
Low Back Pain; Chiropractic; Rehabilitation; Exercise Therapy

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