A new method to determine proprioception impairment in patients with back pain and patients who underwent back surgery

The aim of the study: The aim of the present study is to describe a new method for proprioception measurement and demonstrating the proprioceptive dysfunction by using the repositioning error method in patients who have back pain or those who underwent back surgery. Materials and Methods: The patients were assigned into three groups. The inclusion and exclusion criteria for each group were specified. The inclusion criteria for the healthy group (Group A) were (a) not developing back pain in the last six months, (b) not complaining from back pain lasting longer than six months and (c) having no spinal problems. The individuals with back pain requiring medical, physical or immobilization therapy lasting longer than six months or those who received such a therapy in the last six months and those with spinal problems were excluded from Group A. 23 men and 7 women were included in the healthy group. The ages of the individuals in the healthy group hovered between 22 and 55 (mean age=33.50, standard deviation=10.68). The individuals to be included in the second and third groups were chosen among the people who had applied to the Orthopedics and Traumatology Outpatient Clinic of Dokuz Eylül University between November 2006 and April 2007. The second group (Group B), which was the back pain group, included the individuals who had back pain lasting longer than six months, those receiving physical therapy due to back pain, the patients whose pain continued in spite of the received therapy and that receiving immobilization therapy. The patients who were excluded from Group B were those who had not been complaining from back pain for the last six months, those without a history of back pain lasting longer than six months and the patients with back pain, which did not cause loss in workforce and require physical therapy. 23 men and 7 women were included in the back pain group. The ages of patients in this group changed between 30 and 62 (mean age: 44.03, standard deviation: 9.07). The subjects in the third group, which was the operated group (Group C), were chosen among those patients who had undergone back surgery due to problems causing back pain. The individuals excluded from Group C were the patients who had undergone surgery due to problems other than those causing back pain and those patients who had undergone surgery following spinal cord trauma. 8 men and 8 women were included in this back surgery group. Their ages changed between 24 and 59 (mean age= 43.93, standard deviation: 10.82). Spheres with specified dimension (16.6 mm), which were used for measurement, were positioned on the skin above the C7, T7, T12 and L5 spinous processes of the individuals included in the study. Two tripods, one placed in the back of and the other placed on the right side of the patient, were situated at an equal distance and height from the spheres. Two Nicon Coolpix 4500 cameras with identical image adjustments were placed on the tripods. The patients performed bending movements thrice in three directions: to the front, to the right and crosswise. Six images were taken by each of the two cameras. The first three images were taken in the neutral position before each bending movement and the other three were taken as the patients returned to their initial positions after the performance of the three movements (to the front, to the right and crosswise). The images taken in the neutral position and those taken after returning to the initial position subsequent to the bending movement were overlapped by using Adobe Photoshop. The obtained image was transferred to DicomWorks software for measurement. In order to ensure standardization in the study, the spheres with a previously specified diameter of 16mm were used during the measurement. The distance between each identical sphere in the overlapped photographs was measured in millimeters and the measurements made for each of the four spinous levels were recorded. Statistical Analysis: The data obtained by the photographs taken were loaded into SPSS for Windows 11.0 and the analyses of the images were made. The mean values and standard deviations of the measurements were calculated. In order to determine whether there was a significant difference between the groups in terms of gender, Chisquare tests were performed. When the measurement values of the three groups needed to be compared as a whole, Kruskal- Wallis Variance Analysis was used. When the result was significant according to the given analysis, Mann-Whitney U test with Bonferoni correction was used to determine the group causing the significance. Under parametric conditions, the t-test for independent groups and under non-parametric conditions, Mann-Whitney U test was used. Results: No significant difference was determined between the groups according to the Chi-square test (p=0.130). The mean age was 33.5±10.7 (22-55) in the healthy group, 44.0±9.1 (30-62) in the back pain group and 43.9±10.8 (24-59) in the operated group. According to the Kruskal-Wallis analysis, significant differences in terms of mean age were determined between the groups (p<0.001). According to the Mann-Whitney U test with Bonferoni correction, which was used to determine the origin of the difference, the difference resulted from the healthy group and the mean age of the healthy group was significantly smaller than the remaining groups. The photographs taken from the rear after the bending movement to the right showed a significant difference between the healthy group and the other two groups (back pain and operated groups) in all levels (C7, T7, T12 and L5) while a statistically significant difference was not determined between the operated group and the back pain group. According to the photos taken from the rear after crosswise bending, a statistically significant difference was present between the operated and healthy groups and between back pain and healthy groups in all levels. However, no statistically significant difference was determined between the operated and back pain groups. In the photographs taken from the right side of the patients after the bending movement to the front, statistically significant differences were determined between the operated and healthy groups and between the back pain and healthy groups at all levels, however, there was no significant difference between the operated and back pain groups. In the photographs taken from the right side after crosswise bending, statistically significant differences were present between the operated and healthy groups and between the back pain and healthy groups in all levels except T12, while a significant difference was not determined between the operated and back pain groups. As for the T12 level, significant differences were observed between the operated and healthy, the back pain and healthy and the operated and back pain groups. Conclusion: In this study, a new method, which can be used in the measurement of spinal proprioception and has not been previously mentioned in the literature, is described. This method consists of the measurement of the repositioning error via digital optical imaging. As the results between the study groups were compared, it was concluded that this method could be used in the measurement of the spinal repositioning error and the repositioning error was increased among the individuals with back pain and those who underwent back surgery, compared with individuals without back pain. However, due to the difference in age between the healthy group and the back pain and back surgery groups and the likeliness of a significant difference that may result from the difference in age, it cannot be concluded that this increase results exclusively from back pathologies. It was determined that gender did not affect the results. A similar study on various pathologies causing back pain performed in new patient groups of the same age may be helpful in elucidating the problem causing spinal repositioning error. Similarly, further studies measuring the effects of proprioceptive exercises on the problems associated with back pain by using this method may be beneficial.