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One investigator R. All outcome measures are valid 29 , 30 and reliable 27 , The DN4 is a clinician-administered questionnaire consisting of 10 items for neuropathic pain screening. QDSA has 58 word descriptors categorized into 16 subgroups, including 9 sensory groups and 7 affective groups.
The participants select the word descriptors and score them from 0 not at all to 4 extremely.
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A second investigator T. A neuro-dynamic test, the slump test 32 , was also conducted. The mobilization was performed in a consultation room, very close to the scanner distance: 30 meters , and equipped with a classic medical examination table. A mechanical floor weighing scale Seca , Hamburg, Germany was placed under the feet of the orthopaedic manual physical therapist OMPT to record the change in weight exerted during PA mobilization.
At this point in time, neither of the two investigators were informed of the results of the initial imaging. Pain ratings and trunk mobility tests were again recorded by the two investigators. The time spent in sitting position between the first and second MRI assessments was similar and the 30 meters that separated the treatment and MRI rooms were walked immediately after the sitting position for both MRI assessments.
The principal investigator T. It also allowed the OMPT to reassess the participant following spinal mobilization. Anatomical level L 1 -L 2 to L 5 -S 1 and location central or unilateral were chosen, by palpation during PA mobilization, as the most painful and stiffest sites. The slump test was considered as painful P , when pain was radiating below the knees and not painful no P when not.
Two lumbar MRI scans were performed for each participant, one before and one after spinal mobilization. All sessions were conducted at the same time of the day — PM to control fluid diurnal variations content in IVDs. The procedure used for image acquisition was similar to that described by Beattie et al. All images were obtained using a 1. Multi-element spine coils were used for the T2-weighted and DW images.
An abdominal coil was also used for the DW images. Participants entered the scanner head first, with the hips and knees flexed to approximately 30 degrees. Spin echo techniques were used to obtain T2-weighted sagittal and axial views using the parameters described in Table 2.
DW image parameters are also summarized in Table 2. There was no inter-slice gap and voxels size of 2. A 3-level modified version 10 of the grading system initially developed by Pfirrmann et al.
Intensity brightness and T2 signal homogeneity in the central region of midsagittal images was estimated for all IVDs. Hyperintense, homogenous, bright-white NP, with a clear distinction between the AF and NP was graded as 1 normal ; inhomogeneous, gray NP, that can be distinguished from the AF as 2 intermediate ; and inhomogeneous, gray or black NP that cannot be distinguished from the AF as 3 hypointense. After the images were obtained, the files were saved and transferred to a remote workstation for analysis. The radiologist and one investigator R. The ROIs location was determined visually, without using a preset spacing.
Anterior ant. Values before the intervention are represented by the circles in the foreground and the ones after the intervention in the background. All statistical procedures were performed with SigmaPlot software Version Data are presented as means and SD and were checked for normality Shapiro-Wilk and equal variance tests. The Kaiser 39 rule of eigenvalues greater than 1 and the scree plot 40 of the percentage of explained variances by each component as a percentage of the total variance were used to determine the number of relevant components.
The investigator R. The maximal weight change for all participants observed during PA application was PCA results are presented in Fig. This plot shows the proportion of total variance in the data included in the PCA for each principal component dimensions , in descending order of magnitude.
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The scree plot confirms the choice of the first three components to summarize the data cumulative percentage of variance of Dim 1 mobility , 2 pain , and 3 diffusion denotes the three first dimensions or components, explaining 34, PCA results are summarized in 3 correlation circles showing vectors pointing away from the origin to represent the original variables Fig.
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. 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.