Reposition Sense of the Knee Joint - Essay Example

Running head: LBP AND REPOSITION SENSE OF THE KNEE JOINT Reposition Sense of the Knee Joint in Individuals with and without Low Back Pain Halima Tabani [Institute's Name] Running head: LBP AND REPOSITION SENSE OF THE KNEE JOINT 26th May 2009 Reposition Sense of the Knee Joint in Individuals with and without Low Back Pain Low Back Pain (LBP) is one of the most common problems encountered in orthopedic practice nowadays as it is a condition which causes significant morbidity to the patient and is potentially disabling. It has been defined as "pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica) (MTABC, 2004)." It is important to remember that LBP is a symptom rather than a diagnosis and therefore, elucidation of the underlying cause of the back pain and its proper treatment is imperative in the treatment of back pain rather than just providing symptomatic relief to the patient. Back has been found to be the second most common pain location in the human body and thus LBP has a considerably high prevalence (BenDebba, et al., 2002). This problem is important from the public heath perspective as it affects a considerable proportion of the population and carries with it numerous direct and indirect costs. LBP has been shown to impair an individual's quality of life and his/her functioning. The magnitude of the burden of this problem in the society can be gauged from the fact that the point prevalence of LBP in the general population has been reported to be 15-30% while its lifetime prevalence can be as high as 60-80% (MTABC, 2004). However, the duration of symptoms of this disorder can be reduced viz appropriate and timely management and a study conducted by Waddell et al. elucidated that almost 67% of patients who had taken time off from work due to LBP has returned to work within 1 week and within 2 months almost 90% of the patients became symptom free (MTABC 2004). The etiology of LBP is diverse and it can be attributed to a multitude of causes including the degeneration of the lumbar intervertebral discs, spondylosis deformans (Luoma, et al., 2000 cited in Hangai et al., 2006), osteoarthritis, spinal stenosis, disc disease, dysfunction of the sacoroiliac joint, cancers, infection, organ-related pain, inflammatory arthritis (MTABC 2004), spondylolisthesis and compression fractures which commonly occur due to osteoporosis (Shirakihara, et al., 2001 cited in Hangai et al., 2006). Moreover, several studies have also reported factors such as weakness of the abdominal and back musculature (Van Tulder, et al., 2002), physical loading of the lumbar spine (Bahr, et al., 2004 cited in Hangai et al., 2006) and arteriosclerosis of the abdominal and lumbosacral arteries (Kauppila, et al., 2004 cited in Hangai et al., 2006). Interestingly, the role of psychological factors has also been implicated in the etiology of low back pain by some studies (Takeyachi, et al., 2003 cited in Hangai et al., 2006). The diversity of pathologies which can manifest as back pain often leads to difficulties in determining the underlying pathology and thus makes diagnosis challenging. Similarly, knee pain has also been known to be triggered by a variety of factors such as obesity, increasing age and trauma. Moreover, female gender has been proven to be a definite risk factor for knee pain. Other factors such as ethnicity, smoking, osteoporosis, knee-periarticular muscle strength and exercise have also been implicated in the aggravation of pre-existing knee pain by certain studies (Fukuda and Nakamura, 2002; Burger et al., 1996; Cheng, et al., 2000 cited in Hangai et al, 2006) but these findings have not been replicated by further studies and a causal relationship between these factors and knee pain is yet to be proven. LBP can produce a varying range of symptoms depending on the specific causes. The location and radiation of LBP varies with the pathology and some diseases may cause more back pain than leg pain while others cause greater leg pain as compared to the back pain. Correct identification of the pain location and its distribution often helps in discerning the specific cause of the pain, For example, spinal stenosis gives rise to pain in the buttocks, thighs, or calf region following or on activity while sciatic nerve compression can manifest as parasthesias in the lower extremities, muscle weakness typically of the lower limb and bladder or bowel incontinence (BenDebba et al. 2002). These symptoms are usually unilateral. Similarly, disc herniation can also give rise to symptoms of lower extremity pain and its specific distribution varies with the level at which the disc has herniated for example L4/5 or L5/S1 disc herniation typically manifests as leg pain (MTABC 2004). Among the many manifestations of LBP and knee pain, an important long term consequence of LBP and knee pain is a reduction in the volume of the musculature of the lower extremities. This relationship was demonstrated by Hangai et al (2006) in their study of 156 individuals who were aged over 60 years and were suffering from either LBP or knee pain. The muscle volumes, thickness and muscle transactional areas were measured using different methods which have been validated and recommended by previous studies. The results of this study revealed that LBP was significantly associated with a reduction in the thickness of the latissimus dorsi muscle while knee pain was shown to be related to a loss in the volume of the anterior femoral muscle. These findings have several different implications. Firstly, from a treatment perspective, it can be hypothesized that strengthening the muscle power via measures such as exercise can help in the improvement of symptoms. On the other hand, if the consequences of the loss of muscle volume are contemplated upon, it can be postulated that such a condition would inevitably lead to a reduction in muscle strength and thus lead to easy muscle fatigability. Consequently, this muscle fatigue can potentially lead to other problems such as those of gait and the reposition sense. Positioning sense or proprioception refers to the 'sensations arising in special end organs which were adapted for excitation by changes going forward in the organism itself (Givoni, Pham, Allen, & Proske, 2007).' Proprioception is one of the most important sensations in the body as it helps in the maintenance of a particular posture, balance and orientation. It has two main components, viz. static and dynamic (Newcomer, Laskowski, Yu, Jo, & An, 2000). Under this umbrella term, there is included a term 'kinaesthesis', which is the ability of the body to recognize the precise location of its various parts (Givoni, Pham, Allen, & Proske, 2007). The kinesthetic sense of the knee is important in that it serves in the maintenance of a proper steady gait and it has been established that exercise comprises this ability by virtue of causing fatigue. The effects of muscle fatigue on the positioning sense of the knee joint was investigated by Givoni et al. (2007), whereby they investigated the effects of both eccentric exercise (during which the exercising muscles lengthens) and concentric exercise (during which the exercising muscle shortens) on the knee positioning sense in eighteen healthy subjects (Givoni, Pham, Allen, & Proske, 2007). The results yielded showed that after exercise of the quadriceps, the sense of proprioception or the kinaesthetic ability of the knee joint became impaired and led to matching errors. This was explained by the authors as being due to the effect of fatigue which led to the perception of the muscle as longer than its actual length and thus causing matching errors (Givoni, Pham, Allen, & Proske, 2007). The authors also postulated that similar effects can be caused during sports or exercise leading to increased chances of error and thus greater incidences of injuries in fatigued athletes (Givoni, Pham, Allen, & Proske, 2007). Similarly, it has also been proven by previously conducted studies that amongst individuals suffering from low back pain the lumbar flexor and extensor muscles undergo fatigue very rapidly (Hart, Fritz, Kerrigan, Saliba, Gansneder, & Ingersoll, 2006). This is because in individuals with low back pain, the muscles have poor strength and endurance and thus are prone to fatigue easily as compared to normal, healthy muscles (Hart, Fritz, Kerrigan, Saliba, Gansneder, & Ingersoll, 2006). Moreover, rapid fatigue of the lumbar paraspinal muscles is also associated with a greater degree of quadriceps inhibition. This can in turn lead to gait alterations and the body begins to undertake compensatory force attenuation strategies (Hart, Fritz, Kerrigan, Saliba, Gansneder, & Ingersoll, 2006). Hart et al. undertook a study in order to investigate the above mentioned relationship and compared the activation of the quadriceps muscles amongst normal individuals and those with low back pain, after a period of lumbar paraspinal fatiguing exercise (Hart, Fritz, Kerrigan, Saliba, Gansneder, & Ingersoll, 2006). At the conclusion of the study, it was found that fatiguing lumbar paraspinal exercise led to decreased activation of the quadriceps muscles, despite the absence of quadriceps fatigue (Hart, Fritz, Kerrigan, Saliba, Gansneder, & Ingersoll, 2006). Similarly, Suter and Lindsay also demonstrated reduced quadriceps activation in individuals suffering from low back pain after extended isometric contraction which led to paraspinal muscle fatigue (Hart, Fritz, Kerrigan, Saliba, Gansneder, & Ingersoll, 2006). This reduction in the activation of the quadriceps muscles leads to important consequences such as kinematic and kinetic alterations in gait and impaired ability to respond to joint loading. Moreover, from a management perspective, conservative management for low back pain, such as manipulation of the sacroiliac joints, has been shown to cause quadriceps disinhibition in individuals who had concurrent symptoms of knee pain along with back pain (Hart, Fritz, Kerrigan, Saliba, Gansneder, & Ingersoll, 2006). Thus, keeping in mind the above discussed studies, it is clear that in the case of fatigued muscles, in particular quadriceps, the position sense is affected. Literature supports the fact that LBP is one of the reasons to cause fatigue in the quadriceps. However, despite extensive literature review, only a handful of studies were found to examine this possible relationship. For example, Newcomer et al. (2000) elucidated that there was greater incidents of repositioning errors during flexion in individuals with low back pain as compared to normal subjects. This led to the postulation of the hypothesis that low back pain contributes towards a loss in the proprioceptive abilities of affected individuals (Newcomer, Laskowski, Yu, Jo, & An, 2000). An investigation in to this arena to explore the different possible outcomes of low back pain is thus required and these findings are in conjugation with the underlying hypothesis and purpose of the current study that there are differences in position sense between individuals with low back pain compared with healthy individuals. In sum, studies have shown a direct relationship between the effects of fatigue on the muscles of the lower back (paraspinal) and the lower limb muscles (quadriceps) all of which have attachments around the knee joint. The findings of the above mentioned studies can be summarized as follows: (1) Low back pain is a common problem in today's society and has a high burden and thus needs to be addressed, (2) among other consequences of low back pain, an important consequence is a reduction in the volume of the lower limb muscles, (3) this reduction in muscle volume contributes towards easy fatigability of the lower limb muscles, (4) low back pain itself contributes towards a reduction in the activation of quadriceps muscles indirectly via causing fatigue of the paraspinal muscle, despite the fact that the quadriceps muscles are not fatigued (5) muscle fatigue impairs the proprioceptive abilities of the limb thus leading to repositioning errors. In combining the above mentioned findings and the results of Hart et al. (2006), Hangai et al (2006) and Newcomer et al. (2000) it can be concluded that enough clinical evidence exists that LBP affects the muscle strength of lower limb which leads to muscle fatigability. On the other hand, such muscle fatigue has a direct effect on position sense (Ribeiro et al, 2007). Hence it can be hypothesized that low back pain would affect the repositioning sense of the knee joint. Therefore, this study aims to investigate the effect of low back pain on position awareness at the knee. The researchers hope to investigate whether there is a difference in this awareness between people who have low back pain and people who don't since till date there exists a paucity of studies which have explored this arena. Findings from this study may contribute to developing a better understanding of the effect of low back pain on posture and movement at the knee. This information may help in the future assessment and treatment of low back pain. Moreover, it can help in the development of strategies to prevent the occurrence of such outcomes by the early recognition of low back pain and the provision of timely and prompt management so that long time hazardous consequences do not develop. References BenDebba, M., Torgerson, W. S., Boyd, R. J., Dawson, E. G., Russell W. Hardy, Robertson, J. T., et al. (2002). Persistent Low Back Pain and Sciatica in the United States:Treatment Outcomes. Journal of Spinal Disorders & Techniques , 2-15. Givoni, N. J., Pham, T., Allen, T. J., & Proske, U. (2007). The effect of quadriceps muscle fatigue on position matching at the knee. Journal of Physiology , 111-119. Hart, J. M., Fritz, J. M., Kerrigan, D. C., Saliba, E. N., Gansneder, B. M., & Ingersoll, C. D. (2006). Reduced Quadriceps Activation After Lumbar Paraspinal Fatiguing Exercise. Journal of Athletic Training , 79-86. MTABC. (2004). Low Back Pain Literature Review. Canadian Institute for the Relief of Pain and Disability and the Massage Therapists Association of British Columbia. Newcomer, K. L., Laskowski, E. R., Yu, B., Jo, J. C., & An, K.-N. (2000). Differences in Repositioning Error Among Patients With Low Back Pain Compared With Control Subjects. Spine , 2488-2493. Suter E, Lindsay D. Back muscle fatigability is associated with knee extensor inhibition in subjects with low back pain. Spine. 2001;26:E361-366. Read More