Journal of Back and Musculoskeletal Rehabilitation

BACKGROUND: Neck pain is considered to be a major health problem in modern societies. Many previous studies found that certain occupations are related to this problem or are associated with the risk of developing it in future. Although the pain is caused by mechanical factors, it may progress to a serious problem and give rise to other abnormal symptoms such as vertigo, headache, or migraine.

OBJECTIVE: To investigate the prevalence of neck pain among the cabin crew of Saudi Airlines.

DESIGN OF STUDY: A cross-sectional study was carried out on the available Saudi Airlines cabin crews in King Fahad Airport during our visits, using questionnaires and measurements of several parameters.

METHODS: Neck Pain Questionnaires were distributed to the cabin crews on Saudi Airlines and assessment sheets were completed by all participants of the study to evaluate the prevalence and distribution of neck pain. Physical therapy examination of neck motions in different directions and specific tests were performed by all the participants to identify any symptoms. Using these data the prevalence of neck pain among the cabin crews was calculated. Collected data were analyzed statistically using SPSS software calculating the mean, median, and score of the questionnaire.

RESULTS: According to the scoring system of the study, 31(30.09%) of 105 cabin crew staff of Saudi Airlines had neck pain. Our study confirmed a positive correlation between this occupation and neck pain, and in fact found that according to the results of logistic regression analysis, this occupation is the only significant factor that affects the positive compression test.

CONCLUSION: The prevalence of neck pain among the cabin crews of Saudi Airlines was emphasized. The results show a high prevalence of neck pain in the participants of the study, with most cases appearing to run a chronic - episodic course. Further research is needed to help us understand more about the long-term course of neck pain and its broader outcomes and impacts.

OBJECTIVE: The aim of this study was to investigate sleep quality in patients with chronic low back pain (CLBP) and its relationship with pain, functional status, and health-related quality of life (HRQOL).

METHODS: Two hundred patients with CLBP aged 20-78 years (mean: 50.2 years) and 200 sex- and age-matched pain-free healthy controls (HCs) aged 21-73 years (mean: 49.7 years) were included in this study. After lumbar region examination, in patients, pain was evaluated with the Short Form-McGill Pain Questionnaire (SF-MPQ), functional capacity with the Functional Rating Index (FRI), and health-related quality of life with the Short Form-36 (SF-36). The Pittsburgh Sleep Quality Index (PSQI) was used to evaluate sleep quality of both groups.

The sleep quality was compared between the patients and HCs. In patients with CLBP, its relations with pain, functional status and HRQOL were also investigated.

RESULTS: The patients had significantly higher total scores(8.1 ± 4.3, 4.6 ± 3.4, P< 0.001, respectively) and subscale scores(P< 0.001) for PSQI compared to HCs. The groups were only similar in use of sleeping medication (P> 0.05) Among the patients, sleep quality was worse in women, in the patients with complaints more than 11 years, in the patients with low back and two leg pain (P< 0.05). Mean scores of the FRI, SF-MPQ, and visual analog scale in the patients were 8.5 ± 3.0, 16.7 ± 8.0, 6.9 ± 1.2, respectively. The PSQI total scores of patients were positively related with both SF-MPQ and FRI scores (P< 0.001). Also, there were negative relationships between the physical component summary score of the SF-36 and all subscale scores of the PSQI, without sleep duration of PSQI (P< 0.001).

CONCLUSION: The sleep quality of patients with CLBP was worse compared to HCs, and there were positive relations between the sleep quality with pain and functional status. Also, the poor sleep quality had negative effect on the physical component of quality of life.

INTRODUCTION: The Bournemouth Questionnaire (BQ) was used to report the short to mid-term outcome of a prospective cohort of patients who had sustained Whiplash Associated Disorder (WAD), and establish whether outcome could be predicted on initial assessment.

METHODS: One hundred patients with WAD grades I-III on the Quebec Task Force Classification were referred for physiotherapy (neck posture advice, initially practised under the direct supervision of a therapist). BQ scores were recorded on the first visit, at six weeks, then at final follow-up.

RESULTS: Seventy-six percent of patients were available at final follow-up, 58% women. The mean age was 43.2 years old and follow-up time 38 months (28-48). Symptoms plateaued after six weeks in the majority and improved gradually thereafter. When the individual BQ components on initial presentation were reassessed, patients who score disproportionately highly in BQ Question 5(Depression) had a worse outcome. To quantify this, the ratio of BQ Questions 5 (Depression)/1 (Pain) was calculated. BQ5/1 ratio greater than 1 on initial presentation had an odds ratio of 2 for poor outcome (p= 0.02).

CONCLUSION: The BQ can therefore be used to identify patients with a disproportionately high depression score (BQ5) who are highly likely to clinically deteriorate in the medium term.

BACKGROUND AND AIM: The aim of this retrospective study was to investigate the therapeutic effect of transforaminal epidural steroid injection in patients with chronic low back pain and radicular leg pain due to lumbar disc herniation.

MATERIALS AND METHODS: This study included 80 patients (32 female and 48 male; mean age: 45.8 years [range: 25-65 years]) that received fluoroscopically guided transforaminal epidural steroid injections for chronic radicular low back pain due to lumbar disc herniation. All of the patients had diagnostic MRI findings and did not respond to conservative treatment. All injections were performed by the same physician at the interventional pain unit of a tertiary hospital. The effectiveness of transforaminal epidural steroid injections was assessed via a standardized telephone questionnaire administered 2 years after the first injection.

RESULTS: Mean duration of radicular low back pain was 24.50 ± 18.25 months. Most of the epidural injections were administered at the L5 and S1 levels. The most effective post-injection period was the first 5.11± 3.07 months. Mean duration of injection effect was 12.46 ± 7.24 months. The response rate to the epidural steroid injections was 72%.

CONCLUSIONS: There was negative correlation between the duration of treatment effect and the duration of pre-treatment symptoms. Additionally, clinical improvement of radicular low back pain increased significantly as the duration of pre-treatment symptoms decreased. Based on the present findings, we think that transforaminal epidural steroid injections can be used as an alternative treatment for managing chronic radicular low back pain.

BACKGROUND: Scoliosis, the most prevalent orthopaedic condition affecting children and adolescents, may have lasting physical, psychological and social consequences. With limited evidence-base, scoliosis-specific exercise therapies are an option.

OBJECTIVE: An overview of the subject and description of a long-term follow-up study including adults who in adolescence were treated with a scoliosis-specific exercise programme investigating the association of the exercise regime with present physical activity, physical functioning and subjective wellbeing. To the authors' best knowledge, this is the first long-term outcome study on scoliosis-specific exercises, in opposition to a number of studies in adults who were braced or treated surgically in adolescence.

METHODS: Observational, registry-based case-control study. Adult subjects who in adolescence were treated with an exercise programme or were under observation are invited. Spine and trunk deformity, respiratory function, physical capacity and trunk muscles' function are measured. Health-related quality of life with generic and condition-specific instruments, general mental health, depression and anxiety symptoms, disability due to low back problems and physical activity are assessed.

CONCLUSIONS: The report is believed to provide the readers with an overview of this controversial aspect of rehabilitation, and that the proposed protocol will assist researchers designing their studies.

BACKGROUND: Enthesitis is a prominent feature of spondyloarthropathy (SpA) and persisting enthesitis may be a presenting symptom either alone or in combination with peripheral synovitis and/or inflammatory back pain.

OBJECTIVE: To describe a series of SpA patients with persistent enthesitis as first manifestation.

METHODS: This is a cross-sectional study. All SpA patients visiting the rheumatology and rehabilitation clinic, of Chittagong Medical College Hospital, between May 2007 and December 2008, were studied and those with chronic enthesitis as presenting symptom were included. Patients were classified with European Spondyloarthropathy Study Group (ESSG) classification criteria for SpA. Demographic data were collected and routine lab tests performed, including HLA-B-27 testing. In all patients X-ray of spinal segments, sacroiliac joints and pelvis were performed. Collected data were analyzed using SPSS package program (version 12.0) and multivariate analysis was done.

RESULTS: A total of 71 SpA patients could be included with initial presentation with chronic enthesitis. Of these patients 20 gave a history of disease onset before their 16^th birthday and in 51 cases it was after their sixteenth. The mean age at presentation was respectively 12.5 ± 2.5 and 23.3 ± 6.4 years in juvenile and adult cases. Enthesitis was defined by history, clinical examination, and radio-imaging at accessible sites(X-ray pelvis/foot). Enthesitis presenting in the heel was the most common site (n= 51), but it was also seen in other locations in another 20 patients. The mean duration between presenting enthesitis and other features of SpA was 7.7 ± 3.2 and 8.5 ± 2.2 months in juvenile and adult cases respectively. All patients had raised ESR at disease onset and HLA-B27 was found to be positive in 58 cases. Ankylosing spondylitis (AS) was diagnosed in 49 cases and GradeI-II, Grade-III, and Grade-IV sacroiliitis was documented in 31, 5, and 13 patients respectively.

CONCLUSION: Persistent enthesitis is one of the most common clinical presentation of SpA usually associated with high ESR, HLA-B27 positivity. Definition and classification of enthesitis is important in early diagnosis of this rheumatologic condition.

OBJECTIVE: In this study, we investigated the activity of serum relaxin in female patients with benign joint hypermobility syndrome (BJHS), locomotor system findings accompanying BJHS, and its relation to relaxin.

METHODS: Into the study, female patients with BJHS and healthy women as the control group were included. The patients were diagnosed by using the Brighton 1998 criteria. Examination of the locomotor system for study groups were performed. Serum relaxin levels of both patient and control group were measured.

RESULTS: There were 48 female patients with BJHS and 40 healthy women in the study. With respect to the control group, the level of serum relaxin was higher in the patients (47.1 ± 20.3, 34.4 ± 22.1; p> 0.05). Again compared with the control group, arthralgia (p= 0.00), myalgia(p= 0.01), shoulder impingement syndrome (p= 0.05), pes planus (p= 0.01), and hyperkyphosis(p= 0.000) were higher in the patients. The level of relaxin median was significantly higher in the patients with pesplanus and hyperkyphosis than those who did not have them (p= 0.05, p= 0.01, respectively).

CONCLUSIONS: Although serum relaxin level is not considered a causative factor for BJHS, the significant increases found in those patients with hyperkyphosis and pes planus suggest the hypothesis that relaxin has a limited and indefinite role in patients with BJHS.

BACKGROUND: The occurrence of specific low back pain (LBP) due to workplace factors has not been well described among kitchen industry workers. This study would claim various risk factors that contributing LBP among kitchen workers.

OBJECTIVE: The purpose of the study was to examine the risk factors and the prevalence of LBP among the male commercial kitchen workers at catering industry.

METHODS: The study population comprised of 114 male kitchen workers from nine hostel kitchens in a college campus in South India. The reported musculoskeletal symptoms during past 12 months were determined with the help of standardized Nordic Musculoskeletal Questionnaire (NMQ) survey and by direct observations.

RESULTS: The statistical analyses were carried out and the highest prevalence of LBP among subjects was reported as 65.8%. Among different work categories, the Chief cooks were reported highest prevalence of LBP(79.2%) than Assistant Cooks (71.4%) and Kitchen Aids (30.0%). Similarly the upper age group ( ≥ 41 years) workers had experienced the highest discomfort in low back as 92.9% than other age groups.

CONCLUSIONS: Results suggest that to undertake further studies on different preventive measures and ergonomics intervention to reduce the risks of LBP among kitchen workers.

BACKGROUND: Turkish version of the Upper Extremity Functional Index(UEFI) may help to assess shoulder function in patients with shoulder impingement syndrome (SAIS).

OBJECTIVE: To translate and cross-culturally adapted UEFI into Turkish and to assess its acceptability, reliability, validity in patients with SAIS.

METHODS: This study conducted with 93 SAIS participants. UEFI, the short version of the Disability of the Arm, Shoulder and Hand scale (Quick DASH), the Shoulder Pain and Disability Index, and the Short Form-36 Health Survey (SF-36) were administered. Acceptability was assessed in terms of refusal rate, rates of missing responses, and administration time. Test-retest reliability was assessed with intra class correlation coefficient (ICC), internal consistency was assessed with Cronbach's alpha coefficient. Validity was assessed by floor and ceiling effects, skew of distributions and Pearson's correlation coefficients.

RESULTS: Cronbach's alpha coefficients for the UEFI at Time 1 and Time 2 were as follows: α = 0.89 and α = 0.89. Average measure ICC was 0.80. The UEFI score demonstrated strong negative correlations with SPADI total score and Quick DASH score. There was not a significant correlation between the UEFI and mental health subscale score derived from SF-36.

CONCLUSIONS: The Turkish version of UEFI is acceptable, valid, and reliable.

BACKGROUND AND OBJECTIVES: Frozen shoulder is a painful condition with gradual onset and loss of range of motion in the glenohumeral joint. To investigate the efficacy of ultrasound(US)-guided intra-articular(IA) ketorolac injection with capsular distension compared with steroid injection alone in patients with frozen shoulder by assessing pain relief, functional improvements, and range of motion at 1,3 and 6 months after the last injections.

MATERIAL AND METHOD: Between January 2009 and December 2012, 121 patient were treated with US-guided IA steroid injection or IA ketorolac injection with capsular distension for frozen shoulder. Patients (n= 57) of US-guided IA steroid injection group were administered with a mixture of 0.5% lidocaine (4 ml) plus triamcinolone (40 mg/ml; 1 ml) and patients(n= 64) of US-guided IA ketorolac injection with capsular distension group were administered by using 0.5% lidocaine (19 mL) plus ketorolac (30 mg/ml; 1 mL) for capsular distension. Outcome measurement was assessed by Shoulder Pain and Disability Index (SPADI), Verbal Numeric pain Scale (VNS) and passive range of motion (ROM) before injections and at 1, 3 and 6 months after the last injections. We regarded the outcomes as a success if patients obtained significant pain relief (as measured by > 50% improvement in the VNS score and 20 point improvement in the SPASI) at 1, 3 and 6 months after the last injections.

RESULTS: SPADI, VNS and passive ROM were improved 1, 3 and 6 months after the last injections in both groups. The statistical differences were not observed in SPADI, VNS between groups (p< 0.05). Successful treatment rate were not significantly different between the groups as well as in 1, 3 and 6 month outcomes. However, greater improvement was found in a matter of range of motion in patients receiving IA ketorolac injection with capsular distension than participants receiving US-guided IA steroid injection alone. Significant differences in improvement at 3 and 6 months were observed for shoulder passive abduction and external rotation (p< 0.05).

CONCLUSION: IA ketorolac injection with capsular distension was shown to be a treatment method as effective as the steroid injection alone in pain relief and functional improvement in patient with frozen shoulder and more improvement in passive abduction and external rotation than steroid injection alone at 3 and 6 months.

OBJECTIVE: This study was planned to compare of pain, emotional status and disability level in patients with chronic neck pain and low back pain.

METHODS: In this study, fifty patients with chronic low back pain (Group I) and fifty patients with chronic neck pain (Group II) at least 6 months were evaluated. A Visual Analog Scale was used to describe pain intensity. To determine emotional status of the subjects, the Beck Depression Scale was used The Oswestry Disability Index and the Neck Disability Index were used to evaluate disability level.

RESULTS: The mean age of the patients with low back pain and neck pain were 39.70 ± 9.71 years, 45.44 ± 10.39 years, respectively. It was not found a significant difference between in low back pain (Group I) and neck pain (Group II) in results of pain intensity (p= 0.286) and pain duration(p= 0.382). It was found a significant difference between group I and group II in results of emotional status (p= 0.000) and disability level (p= 0.000). The emotional status and disability level scores were found highest in patient's with low back pain.

CONCLUSION: Chronic low back pain is affect in patients than chronic neck pain as a emotional status and disability level.

BACKGROUND: Stair climbing is an important but neglected aspect of independent living. Clinicians should pay attention to the ability to negotiate stairs in elderly and disabled patients.

OBJECTIVE: The aim of this study was to determine the effects of age, gender, medication use, cognitive status, lower extremity pathology and pain on the activities of stair negotiation in the elderly population in Turkish society.

METHODS: Volunteer elderly people (254) were included the study. Participants were assessed in terms of their medication use, cognitive status, lower extremity pathology and pain and the activity of climbing the stairs.

RESULTS: Significant differences were found on the activities of stair negotiation between the elderly with and without lower extremity pathology, with and without lower extremity pain, with and without medication use (p< 0.05). A positive and moderate correlation was found between age and the activity of stair climbing (r= 0.24, p< 0.01).

CONCLUSIONS: Activity of stair climbing is affected by age, medication use, the presence of lower extremity pathology and pain. We consider that this information will be helpful for planning an appropriate and effective rehabilitation programme for elderly people for decreasing their risk of falling and increasing their independence level during their activities of daily living.

BACKGROUND: The most common disease of the older age group in Turkey is degenerative articular disease and pain associated with the disease. Analgesics and physical therapy are preferred treatment for geriatric chronic pain but suffering from multiple medical and nutritional problems in old ages can limit treatment options with analgesics due to an increased risk of adverse effects and drug interactions.

OBJECTIVES: We aim to show the effect of acupuncture on back-pain and knee-pain treatment of elderly people.

METHODS: The study includes 34 patients, 24 female and 8 male. The mean age was 69.0417 ± 8.95 years for females and 73.12 ± 8.95.24 years for males. Every two days for a total of 10 sessions acupuncture treatment to Yintang, Ht 7 (Shenmen), LI 4 (Hegu), Ki 3 (Taixi) and Ki 6 were found to significantly reduce pain scores of patients.

RESULTS: Mean back pain scores(8.8696 ± 1.546) and mean knee pain scores (9.1304 ± 1.4239) of patients were reduced significantly to 2.1739 ± 1.466 and 1.455 ± 0.7; p< 0.001 respectively after the acupuncture treatment.

CONCLUSION: These are important results as they give rationale to use acupuncture treatment widely in chronic low back pain and knee pain in the geriatric group of patients to reduce the side effects of polypharmacy in elderly.

BACKGROUND AND OBJECTIVES: Though core muscles strengthening using upper limbs in various positions and lower limbs in lying have been studied previously in patients with chronic low back pain (CLBP), no study has specifically looked in to the effects of a training program that requires prior motor planning in standing (functional position). The objective of this study was to evaluate the effectiveness of star excursion balance test (SEBT) grid training in improving the outcomes in patients with CLBP.

MATERIALS AND METHOD: Sixty patients with mechanical CLBP who fulfilled our criteria were randomized in to two groups; experimental group received physical diagnostic specific interventions, core muscles strengthening and muscles training using the SEBT grid. The participants in control group received stationary cycling instead of SEBT grid training and the other interventions were uniform. The duration of study was 4 weeks. The dependent variables were analyzed using repeated measures 2 × 3 ANOVA.

RESULTS: At the end of study, both the groups showed a significant reduction in disability and improvement in strength and endurance (p< 0.05). Post-hoc analysis showed that SEBT grid training was better than conventional exercises. Follow-up at 16 weeks revealed a statistically insignificant loss in strength and endurance in control group patients. This reduction was not associated with an increase in disability score. The experimental group patients continued showing improvement.

CONCLUSION: The results of our study show that core muscles strengthening using a SEBT grid are more effective than conventional programs. We hypothesize SEBT training to have a significant role in skill learning. We recommend SEBT grid training to be incorporated in the treatment planning of persons with CLBP.

OBJECTIVE: To evaluate knee proprioception in patients with anterior cruciate ligament (ACL) injuries and to assess the effectiveness of an exercise program consisting mainly of proprioception exercises addressing pain, proprioception, and functional status following ACL reconstruction.

MATERIALS AND METHODS: Twenty male patients, diagnosed with unilateral ACL injury and scheduled for reconstruction, participated in the study along with 16 age- and sex-matched healthy volunteers. Arthroscopic reconstruction of the ACL using autologous hamstring tendon was performed in every case by the same surgeon. After the operation, a six-month rehabilitation program was initiated. Knee proprioception, pain, and functional status were evaluated before and six months after the reconstruction. An isokinetic dynamometer was used to evaluate proprioception and a visual analog scale (VAS) and the Tegner Lysholm Knee Scoring Scale were used to evaluate pain and functional status respectively.

RESULTS: Preoperative proprioception loss was detected on the patients' injured side when compared to the uninjured side and to healthy volunteers (p = 0.00). A significant improvement was found in pain severity, proprioception, and functional capacity after the postoperative six-month rehabilitation program (p = 0.00).

CONCLUSION: Preoperative proprioception loss was detected in ACL-injured patients. The rehabilitation program predominantly consisting of proprioception exercises provided considerable improvement on knee proprioception and functional status.

BACKGROUND: Hospital workers with physically demanding jobs are at risk for developing recurrent LBP. There is a lack of studies evaluating multidisciplinary prevention of low back pain (LBP) in hospital workers.

OBJECTIVE: This randomized controlled trial evaluates the effect of a multidisciplinary prevention program, focusing on a client-centred approach, on hospital workers at risk for developing LBP.

METHODS: Caregiving hospital workers were allocated to an experimental(12-week lasting multidisciplinary prevention program) or control group (no intervention). They were evaluated prior to the intervention and after a 6 months follow-up period. Primary outcome measures included incidence of LBP, work absenteeism and general health. Secondary outcomes included daily physical activity, job satisfaction and coping strategies.

RESULTS: A significant improvement was seen for passive coping after 6 months follow-up, but no significant differences were observed between groups in primary or other secondary outcome measures (p> 0.05).

CONCLUSIONS: A multidisciplinary prevention program fitting into a bio-psychosocial context may not have been intensive enough to promote a change in daily habitudes, and had no effect on work absenteeism, incidence of LBP or general health. Further research should determine whether prevention of LBP is possible in caregiving personnel.

BACKGROUND: Occurrence of musculoskeletal pain in dance sport dancers is often a cause for longer discontinuation of training, which affects the competition results.

OBJECTIVE: The aim of the research project was to determine the age-specific pain experience among male dance sport competitors by defining the proportions of pain status of fourteen body regions.

METHODS: The subject sample of 200 male dancers from 44 different countries and with international competitive experience was divided into three subsamples according to age. Three online questionnaires translated into eight world languages were used for data collection: (1) basic data questionnaire, (2) self-estimated functional inability because of pain questionnaire designed for dancers, and (3) health care-related questionnaire.

RESULTS: After examining the 14 topological regions, it was established that dancers most often report pain in the lower back region(53.5%), followed by knee (43%) and toe regions (40.5%). Significant differences were found using the Chi-square test between the groups of dancers of different ages in the prevalence of pain in the lower back (χ ² = 12.6), shoulders (χ ² = 9.7), and hip region(χ ² = 7), with the highest, age-related progressive differences in the lower back region (36.2-54.9-63.4%) so older dancers had more pain. Often reported reasons for discontinuation of training increased with age are overuse syndrome/tendinitis (6.4-15.9-22.5%) and strain(14.9-29.3-31%). Most common causes for longer discontinuation of training are absence of partner (37%), injuries (24%), and overuse syndrome (10%).

CONCLUSION: Lower back pain is propounding health problem in male dancers and increases with age that cannot be resolved by decreasing training intensity. This research reveals that only 28% of male dancers will seek medical help because of occurrence of musculoskeletal pain. Multidisciplinary approach with the aim of long-term health protection and prolongation of dancing careers is required in future studies.

BACKGROUND: Examination of practice patterns compared to existing evidence identifies knowledge to practice gaps.

OBJECTIVES: To describe the utilization of pharmacological, patient education, primary psychological interventions and relaxation therapies in patients with neck pain by clinicians.

METHODS: An international cross-sectional survey was conducted to determine the use of these interventions amongst 326 clinicians treating patients with neck pain.

RESULTS: Nineteen countries participated. Results were analyzed by usage amongst physical therapists (39%) and chiropractors (35%), as they were the predominant respondents. Patient education (95%) and relaxation therapies (59%) were the most utilized interventions. Tests of subgroup differences determined that physical therapists used patient education significantly more than chiropractors. Use of medications and primary psychological interventions were reported by most to be outside of scope of practice. The high rate of patient education is consistent with supporting evidence. However, usage of relaxation therapies is contrary to evidence suggesting no benefit for improved pain or function for chronic neck pain.

CONCLUSION: This survey indicates that patient education and relaxation therapies are common treatments provided by chiropractors and physical therapists for patients with neck pain. Future research should address gaps associated with variable practice patterns and knowledge translation to reduce usage of interventions shown to be ineffective.

The skeletal dysplasias are a large, heterogeneous group of genetic disorders characterised by abnormal growth, development and remodelling of the bones and cartilage that comprise the human skeleton. They typically present with disproportionate short stature in childhood, or premature osteoarthritis in adulthood. The latest classification lists 456 disorders under 40 group headings differentiated by specific clinical, radiographic and molecular criteria. Establishing an accurate diagnosis is important to predict final height, expected complications and treatment, and for specific genetic and psychological counselling. In addition to the skeletal disorder, individuals frequently demonstrate abnormalities of hearing, vision, neurological, pulmonary, renal or cardiac function that require multidisciplinary assessment. This review provides a guide to diagnosis and discusses management principles for the common limb and spinal abnormalities that affect quality of life for the majority.

BACKGROUND: There are many types of treatments and recommendations for restoring back deformities depending on doctors' knowledge and opinions. The purpose of the exercises is to reduce pain and to ensure stability of the lower trunk by toning the abdominal muscles, buttocks and hamstrings. Given the duration of flares and relapses rate, it is important to apply an efficient and lasting treatment.

OBJECTIVE: To evaluate the effects of 8 weeks of William's training on flexibility of lumbosacral muscles and lumbar angle in females with Hyperlordosis.

METHODS: Forty female students with lumbar lordosis more than normal degrees (Hyperlordotic) that were randomly divided into exercise and control groups were selected as the study sample. The lumbar lordosis was measured using a flexible ruler, flexibility of hamstring muscles was measured with the active knee extension test, the hip flexor muscles strength was measured using Thomas test, the lumbar muscles flexibility measures by Schober test, abdominal muscles strength measured by Sit-Up test and back pain was measured using McGill's Visual Analogue Scales (VAS) questionnaire. Data were compared before and post-test using independent and paired t-testes.

RESULTS: Results showed that 8 weeks of William's exercise led to significant decreases in lumbar angle and back pain, increases in flexibility of hamstring muscles, hip flexor muscles flexibility, lumbar extensor muscles flexibility and abdominal muscles strength.

CONCLUSION: The findings show that William's corrective training can be considered as a useful and valid method for restoring and refining back deformities like as accentuated back-arc and became wreaked muscles' performance in lumbar areas.

We report the case of a 53-year-old male with a right Achilles tendinosis, who complains about a mild gait disorder starting after walking several kilometers. In the following months he develops neurological symptoms. MRI lumbar spine shows an intramedullary tumor at level Th12. A biopsy confirms the diagnosis of an intramedullary astrocytoma. Primary intramedullary tumors are relatively rare. Clinical presentation is often insidious. The authors want to make a point to reconsider a diagnosis in case it does not explain completely the anamnestic or clinical findings. According to the literature there is no optimal approach to the management of these tumors.

BACKGROUND: Disc herniation is one of the most common causes of low back pain with radicular pain. Among various types of disc herniation, the extraforaminal disc herniation is a rare cause of lumbar radiculopathy. The aim of presenting this case study is to demonstrate the benefits of Chiropractic care including spine and extremity manipulation and rehabilitation in the treatment of a rare case of extraforaminal L4 nerve entrapment causing severe L4 radiculopathy and chronic mild low back pain(LBP).

OBJECTIVE: The aim of presenting this case study is to demonstrate the benefits of Chiropractic care including spine and extremity manipulation and rehabilitation in treatment of rare case of extraforaminal L4 nerve entrapment which caused severe L4 radiculopathy and chronic mild low back pain (LBP).

METHOD: A 45-year old female patient arrived at the clinic with chronic mild low back pain and right buttock pain, all of which had presented for two years' duration. During the preceding month, the radicular pain initiated in medium to high intensity, radiating to her right leg following the L4 dermatomal pattern with a periodic tingling sensation in her right foot. A neuro exam demonstrated a proprioception deficit in her right leg. A Romberg test was positive. The patient was treated by low amplitude high velocity spinal and extremity manipulation for 10 consecutive sessions (2 weeks), followed by rehabilitation and exercise therapy including advanced myofascial release therapy for an additional 12 sessions(4 weeks).

RESULTS: After treatment, the patient reported a significant improvement in her low back pain and radiculopathy. In addition, she achieved some improvement in balance.

CONCLUSION: It seems that Chiropractic care and rehabilitation therapy may be a safe and effective modality in treatment of an L4 radiculopathy in a patient with an extraforaminal L4 nerve entrapment. Although it is rare, an L4 extraforaminal disc herniation should be considered as a possible cause of symptoms in patients with chronic mild low back pain and severe L4 radiculopathy.