Alexander Phd thesis 2014 Effect

393 Pages·2014·5.05 MB·English

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ALEXANDER, L. A., 2014. The effect of position on the lumbar
intervertebral disc. Available from OpenAIR@RGU. [online].
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The effect of position on the lumbar intervertebral disc

Lyndsay Ann Alexander

A thesis submitted in partial fulfilment of the requirements of Robert
Gordon University for the degree of Doctor of Philosophy

January 2014

The effect of position on the lumbar intervertebral disc
Lyndsay Ann Alexander
A thesis presented for the Degree of Doctor of Philosophy

Abstract
This thesis comprises three phases with a combined aim which was to
investigate the effect of position on the lumbar intervertebral disc (IVD).
The effect of position on the lumbar IVD in asymptomatic subjects and subjects
with discogenic low back pain (DLBP) was explored using positional Magnetic
Resonance Imaging (pMRI). Convenience samples of 11 asymptomatic and 34
DLBP subjects were recruited to have sagittal and axial pMRI scans performed in
sitting (Neutral, Flexed and Extended), standing and lying (Supine and Prone
extension) positions.
The sagittal plane migration of the nucleus pulposus (NP) of each lumbar IVD in
each position was measured from the sagittal and axial pMRI scans.
Within and between group inferential analysis was performed using non-
parametric tests. Both the asymptomatic and DLBP subjects’ demonstrated that
position had statistically significant effects on the sagittal plane NP migration.
Both groups demonstrated significantly greater posterior sagittal plane NP
migration in Neutral and Flexed sitting positions compared to the other
positions. However, between group comparisons identified that the
asymptomatic subjects also demonstrated significantly greater posterior sagittal
plane NP migration than the DLBP subjects. This pattern was more common in
the upper lumbar IVDs (L1/2 and L2/3) between positions and less common in
the lower IVDs (L4/5 and L5/S1) between positions.
New knowledge regarding the behaviour of the lumbar IVD emerged from this
research. The differences detected between the asymptomatic and DLBP
subjects suggest that some current theories regarding DLBP may be incorrect.
The results also support imaging of DLBP subjects in sitting positions as opposed
to current supine positions. Although the limitations of the study reduce
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generalisation of the results, the implications for clinical practice, imaging and
suggestions for further research from this work are important to improve
understanding and conservative management of DLBP.

Keywords: Intervertebral disc, Discogenic low back pain, Nucleus pulposus,
positional Magnetic Resonance Imaging
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Acknowledgements
There are many people who have contributed in some way towards the
completion of this thesis, and I am extremely grateful to them all. In particular,
thanks are due to the following people:
Mrs Elizabeth Hancock, Head of School of Health Sciences, supervised this work.
I thank her for inspiring and encouraging me from my undergraduate training up
to this stage. Without her encouragement and advice this research would not
have occurred. In addition, I thank her for her valuable advice, support and
guidance throughout this research process.
Dr Kay Cooper, Lecturer, supervised this work. I thank her for her constant
support (especially in the latter stages), valuable advice and guidance
throughout this research process.
Dr Sylvia Wilcock supervised this work. I thank her for providing valuable
advice, support and guidance throughout the research process.
Professor Frank Smith, Consultant Radiologist for his expertise and support on
pMRI in this research.
Mrs Beverley McLennan, Senior MRI radiographer for her professionalism,
expertise and support in developing the imaging protocols, initial testing and
ensuring the pMRI data collection went to plan.
Dr Alex Wilson, statistician for his helpful advice and support on statistics.
The pMRI Centre staff for their support and efficient service during data
collection for all subjects.
NHS Grampian and private practice physiotherapy staff that assisted the studies
by recruiting patients.
The patients, and the staff and students of the Robert Gordon University who
volunteered as subjects for the studies.
School of Health Science staff for encouragement and support over the last 7
years.
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My family and friends for encouraging and supporting me, but also for looking
after Andie over the last 12 months so that I could focus on completing this
thesis.
Finally, I must thank my husband Bill for his continued understanding and
patience throughout this long journey. This thesis would not have been
completed if not for his support. Also, I must thank my daughter Andie, who
came along in the middle of the research, for reminding me there’s more to life
than studying.

This study was also supported financially by grants from NHS Grampian
Endowment Fund, The Chartered Society of Physiotherapy Charitable Trust and
the Alliance for Self Care Research.

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Output
Grants/Awards
2004 I Agouris, E Hancock, FW Smith, LA Alexander. An investigation into back
pain using Positional MRI and Fastrak. £10,500 grant awarded by NHS
Grampian Endowment Fund.
2010 LA Alexander. £1000 awarded by Chartered Society of Physiotherapy
Charitable Trust towards PhD study costs.
2010 LA Alexander. £5,800 awarded by Alliance for Self Care Research towards
Positional MRI costs
2011 LA Alexander. £1610 awarded by Alliance for Self Care Research to
attend World Confederation for Physical Therapy Congress, Amsterdam
(to present results from PhD work).

Peer reviewed articles
Alexander, L.A., Hancock, E., Agouris, I., Smith, F.W., MacSween, A., 2007. The
response of the nucleus pulposus of the lumbar intervertebral discs to
functionally loaded positions. Spine, 32(14), pp. 1508-1512

Presentations
2005 International Conference on Movement Dysfunction (Pain and
Performance: Evidence and Effect), Edinburgh. Oral presentation – “The
effect of functional positions on lumbar nucleus pulposus position”
2005 Chartered Society of Physiotherapy Annual Congress, Birmingham. Oral
presentation – “How does the disc behave in response to functional
positions?”
2007 6th Interdisciplinary World Congress of Low Back and Pelvic Pain,
November 7 – 10, 2007, Barcelona. Oral Poster Presentation –
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“Investigation of the nucleus pulposus response to different functional
positions” (Prize winner)
2010 National Physiotherapy Research Network (North of Scotland Hub), June
2010. Oral presentation – “The Intervertebral Disc”
2011 16th International World Confederation for Physical Therapy Congress,
World Physical Therapy 2011, Amsterdam, Netherlands, 20-23 June 2011.
Poster Presentation – “The effect of position on the intervertebral disc”
2012 Institute for Health and Welfare Research, Robert Gordon University,
Aberdeen. Poster presentation – “The effect of position on the
intervertebral Disc”

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Contents
Page
Abstract--------------------------------------------------------------------- i
Acknowledgements--------------------------------------------------------- iii
Output---------------------------------------------------------------------- v
Contents-------------------------------------------------------------------- vii
List of figures--------------------------------------------------------------- xiii
List of tables---------------------------------------------------------------- xv
Abbreviations--------------------------------------------------------------- xviii

Chapter 1: Introduction---------------------------------------------- 1
1.1: The intervertebral disc------------------------------------------ 2
1.2: Discogenic back pain-------------------------------------------- 3
1.3: Physiotherapy management------------------------------------ 7
1.4: Investigation of discogenic back pain------------------------- 7
1.5: Positional Magnetic Resonance Imaging---------------------- 8
1.6: Structure of thesis----------------------------------------------- 10
1.7: Aims of research------------------------------------------------- 11
1.8: Objectives-------------------------------------------------------- 11

Chapter 2: Literature review---------------------------------------- 12
2.1: Introduction------------------------------------------------------ 12
2.2: The lumbar intervertebral disc--------------------------------- 12
2.2.1: Intervertebral disc morphology------------------------------------ 13
2.2.2: Intervertebral disc innervation----------------------------------- 18
2.2.3: Intervertebral disc blood supply----------------------------------- 19
2.2.4: Nutrition of the intervertebral disc--------------------------------- 19
2.2.5: Intervertebral disc mechanics------------------------------------- 20
2.2.6: Posture and the intervertebral disc-------------------------------- 23
2.2.7: Classification of intervertebral disc pathology-------------------- 25
2.2.8: The intervertebral disc as a pain source-------------------------- 26
2.2.9: Intervertebral disc degeneration----------------------------------- 28
2.2.10: Internal disc disruption------------------------------------------- 34
2.2.11: Intervertebral disc prolapse/herniation-------------------------- 35
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