obtained from skin markers placed over the posterior spinous processes. with pain and disability, led to a change in the back pain paradigm in 1987 when
Unfortunately, the reliability remains too low for accurate inter-vertebral Video- the bio-psychosocial model was introduced
49
. This model approaches the treatment
measurement because the movement of the skin is separate to the movement of CNSLBP from a different angle to the disease model which does not allow for
of the spinous processes
35
. Nevertheless, many clinicians and researchers use fluoroscopy of the complex human response to pain and disability
3
. As a result, the focus turned
goniometry to measure gross trunk motion because it is accessible and non- towards the measurement of social and psychological factors and these have since
invasive, and its reliability in measuring gross overall trunk motion is considered the spine is been used to develop subgroups of CNSLBP sufferers
50
. However, this model fails
acceptable
36
. to acknowledge that there may still be a biomechanical cause for some CNSLBP
again attracting that has, so far, remained undetectable with goniometry or flexion-extension
Flexion-extension radiography has been used traditionally to measure finer radiographs.
inter-vertebral motion in vivo, starting as early as 1904
37
. This is essentially static the attention of
imaging because the patient remains in a fixed position whilst the exposure is Recent advances in medical imaging and computer processing speeds have meant
made. Consequently, information depicting the quality of motion throughout researchers and video-fluoroscopy (as it is now called) of the spine is once again attracting the
the bend is missed, precluding the application of the neutral zone theory
38
. Data attention of researchers and clinicians. In 1989, Breen et al
51
described a technique
obtained with this method are the source of previously published normative clinicians for quantifying inter-vertebral motion using computer algorithms and digitised
ranges for lumbar inter-vertebral levels
39-42
and treatment decisions may be based images from a fluoroscopy unit. This technique evolved into an examination known
on clinical signs, symptoms and ‘abnormal’ motion on radiographs. However, as OSMIA (Objective Spinal Motion Imaging Assessment), for which reliability
measuring inter-vertebral movement from plain radiographs is subject to large has been established
52
. Other groups have also studied spinal motion in both
measurement errors
32,43-45
and little effort is made to account for natural variations symptomatic and asymptomatic participants using video-fluoroscopy
38,53-59
, although
in trunk range. methods used by these groups are not standardised, precluding the pooling of
data.
More recently, focus has turned to dynamic magnetic resonance imaging
(MRI) using open coil scanners to allow full trunk motion. This has the obvious About OSMIA
advantages of not using ionising radiation and visualisation of soft tissue structures OSMIA can be undertaken for the lumbar and the cervical spine. Its main features
but, despite its name, the images are acquired whilst the patient remains static are that it controls the speed and overall range of trunk/neck motion whilst
at differing points throughout the bend. Hence, quality of movement cannot fluoroscopy is undertaken at a rate of 15 frames per second. This standard for
be measured. This method also has an increased scan time which can be acquisition allows comparisons across patient and asymptomatic groups, and
uncomfortable for symptomatic patients. Nevertheless, useful information has controls for the natural variation in trunk range. It also allows radiography to be
come from these studies, including behaviour of the inter-vertebral disc during undertaken in a controlled manner and reduces the issues of flare, rotation or
rotation
46,47
. Open coils, easier accessibility and faster acquisition times without loss movement out of the field of view.
of image quality, may mean that, in time, MRI becomes the method of choice for
measuring continuous inter-vertebral motion. OSMIA of the lumbar spine may be undertaken in the weight-bearing (figure 1) or
recumbent positions (figure 2), in the sagittal and coronal planes.
The lack of information obtained from static imaging has led researchers to
examine the utility of fluoroscopy. The advent of the image intensifier in the 1950s In the weight-bearing examination, patients stand on a specially designed motion
helped realise the advantages of the dynamic approach to studying spinal motion, bucky (Atlas Clinical Ltd) with their hips stabilised. Their trunk motion is guided by
with one of the first fluoroscopic studies of the cervical spine conducted in 1957 an upper disc rotating through a pre-determined range of motion which patients
by Fielding
48
. However, these initial studies were subject to high radiation dose follow. The standard trunk range is 60 degrees flexion and 20 degrees extension,
and poor image quality. Furthermore, the assessment of motion in the spine was accounting for the natural lordosis of the lumbar spine when standing erect. In the
subjective and prone to the same high observer errors as flexion and extension coronal plane it is 40 degrees left and 40 degrees right (80 degrees total). Weight-
projections. Consequently, cineroentgenography (as it was called) did not establish bearing motion of the lumbar spine is influenced by muscle activity which some
itself as an accessible clinical or research tool for some time. may argue is more representative of functional motion.
Poor evidence of a relationship between anatomical pathology, or abnormality However, it is possible that the influence of muscles may inhibit or somehow
36
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IMAGING & ONCOLOGY
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2009
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