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The angle between the vectors is an approximation of the correlation between the variables. A small angle indicates the variables are positively correlated, an angle of 90 degrees indicates the variables are not correlated, and an angle close to degrees indicates the variables are negatively correlated. Additionally, while MRI is a technique capable of providing information both on IVD morphology and molecular composition, research efforts should be directed toward characterizing changes directly linked to clinical symptoms Beattie et al.
Mean age of our population was 46 years with a mean pain intensity at baseline of 5. The mean population age studied by Beattie et al. On the other hand, a difference in body mass index BMI could explain it, since higher values are associated with higher pain intensity levels in patients with LBP 43 , A mean lower value of Normal IVD is poorly innervated and innervation is restricted to the outer annular layers via branches of sinuvertebral nerve, nerve branches from the ventral rami of spinal nerves, or gray rami communicantes Furthermore, nociceptive properties of at least some of these nerves are strongly suggested by their immunoreactivity for substance P.
These observations are used to defend the hypothesis of the existence of discogenic pain in degenerative IVDs. By definition, discogenic pain is due to a mechanical or chemical irritation of nerves supplying the IVD. Based on our results and those of Beattie and colleagues 10 , 11 , 12 , 13 , we believe that the simultaneous reduction in pain observed in patients and increased water diffusion within IVDs is not an epiphenomenon linked to mobilization, and that, on the contrary, these two physiological events are intimately related, directly or indirectly.
Future studies should evaluate such hypothesis. On one hand, IVD degeneration starts in the third decade of life, with NP dehydration and changes in its components molecular structures To our knowledge, changes in trunk mobility have never been studied concurrently with changes in pain and water diffusion within the IVDs.
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Using a PCA, several novel and important observations were made about the relationships between changes in pain, trunk mobility and water diffusion. First, a negative correlation between changes in pain and changes in trunk flexion was observed, but not with changes in extension and lateral flexions. Second, a negative correlation between changes in IVD water diffusion and lumbar anatomic levels was observed. Previous research reported trunk extension 51 , 52 , 53 and flexion 52 mobility to improve or remained unchanged 45 , 46 , 51 after PA mobilization.
We showed a significant increase of Our results suggest that trunk mobility improvements after PA mobilizations could be larger in acute participants than chronic participants. In comparison to previous studies 11 , 12 , 13 , many differences exist and could explain the findings observed: the strategy of PA mobilization application duration, force and frequency , the pragmatic patient-centered therapeutic approach used PA mobilizations applied on the painful anatomical locations with real time pain estimation by an OAS and the selection of grades by the OMPT.
It is generally believed that diffusion is the main transport mechanism for small solutes with convection playing a more important role in the transport of larger solutes DW images provide a characterization of water transport under the combined influence of diffusion and convection. Pressure gradients within IVD could be influenced by externally applied forces, such as those generated by manual therapy techniques 13 , 54 , We hypothesize that water diffusion could be related to opening-closure IVD mechanism. This mechanism has been observed in vivo by Kulig et al.
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A mobilization applied at a given vertebral level results in an extension movement opening at this level and on the upper level, and on the contrary a movement of flexion closure on the lower level. However, in clinical practice, we suggest following the procedure described by Shah et al. Furthermore, static traction was associated with increased water diffusion within the L 5 -S 1 IVDs of middle-age individuals, but not in young adults, suggesting age-related differences in the diffusion response Today, there is a paucity of research describing the physiologic events associated with analgesia following intervention for LBP A significant IVD hyperintense region width was appropriately covered as the IVD volume explored was 15 times greater than that assessed in previous studies 12 , Note that PA mobilizations were applied between L 3 and L 5 in 15 of 16 participants.
This observation is important since nerve fibers have been identified in the NP of degenerated IVDs 61 , which may be more likely associated with pain reduction than healthy IVDs that are thought to be innervated only in the annular part. Pure water, for the purposes of diffusion is said to be isotropic; this means that the molecules are equally likely to diffuse in any direction.
In a biological tissue such as IVD, there may be a preferential diffusion direction, along collagen fibers, and diffusion is said anisotropic. Our methodology did not allow us to study the anisotropic character of water diffusion within IVD. Recently, a promising T2-weighted MRI method based on signal intensity weighted centroid location, i.
It would be interesting to apply this method to our images. This study has some limitations. Nevertheless, an heterogeneous age range is representative of a LBP population 1. From a methodological point of view, the ROIs selected in more degenerated IVDs could have included anatomical structures located outside the hyperintense region. In the future, a rigid image registration method could be used with defined slice placement strategies. However, the large IVD volume assessed in our study compensates for this methodological drawback.
Regarding the different delay in time spent in sitting position between the first and second MRI assessments and the short distance walked by participants, we assume that it could be a bias in comparison with previous studies 11 , In those studies, the observed participants laid during all procedures between the two MRI scans. When lying, the lumbar IVD pressure is much lower compared to sitting and walking 63 , In sitting there is significantly less lordosis than prone lying, and significantly more posterior migration of the NP Another limitation is that we did not plan to study the statistical differences in water diffusion between the anterior, middle, and posterior IVD regions for the different anatomical levels.
Future studies could explore water diffusion in different IVD regions with a larger sample. In conclusion, the specific application of PA mobilizations at the most painful anatomical locations, and guided in real time by pain perception of acute LBP participants, induced increased water diffusion within all lumbar IVDs, except at L 5 -S 1 level. This non-specific, multi-level physiological response was associated with pain and mobility improvements.
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