Using Structural Health Monitoring to Improve Diagnosis and Treatment of Low Back Injury in U.S. Service Members- Phase 2

Low back pain (LBP) is the second most frequent reason for health care visits and a leading
cause of medical evacuation from theater. Traditional medical diagnosis based on static
imaging strategies (e.g. MRI) has failed to improve management of this epidemic. Functional
assessment of lumbar musculature using ultrasound imaging provides evidence of clinically
relevant deficits in the lumbar multifidus (LM) muscle of patients with LBP, however such
procedures are likely only valid within a narrow range of assessment conditions. Shear-Wave
Elastography (SWE) is an evolving non-invasive ultrasound imaging technology capable of
quantifying tissue stiffness (i.e., elasticity). Originally developed to improve diagnosis of
soft tissue tumors, SWE is beginning to be used to as an alternative and more stable method
of functional assessment of muscles.

This study will be the second project in a line of research aimed at improving the diagnosis,
management, and treatment of patients with LBP using a new structural health monitoring
technique called shear wave elastography (SWE). Since no previous studies had used SWE in the
lumbar multifidus muscle, the initial project developed the measurement technique to be used
with this device. We also established normative parameters, variance, and reliability
estimates of SWE outcomes in asymptomatic individuals. A previous study, also performed at
AMEDDC&S, found that individuals with LBP whom received dry needling to the lumbar multifidus
muscle exhibited a reduction in pain and disability that was associated with an improved
ability to contract the lumbar multifidus. The focus of this second project is to evaluate
the diagnostic utility of SWE in individuals after routine low back injury and begin an
initial investigation of it's ability to effectively guide physical therapy treatment with
dry-needling as a relevant treatment intervention.

Inclusion Criteria:

- Between the age of 18 - 65 years

- Read and speak English well enough to provide informed consent and follow study
instructions

- Active duty military or DOD beneficiary

- History of prior surgery to the lumbosacral spine

- Received manual therapy, acupuncture, or dry-needling interventions to the lumbosacral
spine within the past 4 weeks

- Currently taking anticoagulant medications or those individuals with a medical history
of bleeding disorder

- History of systemic inflammatory disease or other serious spinal pathology (e.g.
annular tears of the intervertebral disc, spinal stenosis, fracture)

- Known pregnancy and/or inability to lie prone and fully elevate bilateral arms

- Presence of neurogenic LBP defined by either a positive ipsilateral or contralateral
straight leg raise (reproduction of symptoms at <45°) or reflex, sensation, or
strength deficits in a pattern consistent with nerve root compression

- Medical "red flags" of a potentially serious condition including cauda equina
syndrome, major or rapidly progressing neurological deficit, fracture, cancer,
infection, or systemic disease

Exclusion Criteria:

- History of prior surgery to the lumbosacral spine

- Received manual therapy, acupuncture, or dry-needling interventions to the lumbosacral
spine within the past 4 weeks

- Currently taking anticoagulant medications or those individuals with a medical history
of bleeding disorder

- History of systemic inflammatory disease or other serious spinal pathology (e.g.
annular tears of the intervertebral disc, spinal stenosis, fracture)

- Known pregnancy and/or inability to lie prone and fully elevate bilateral arms

- Presence of neurogenic LBP defined by either a positive ipsilateral or contralateral
straight leg raise (reproduction of symptoms at <45°) or reflex, sensation, or
strength deficits in a pattern consistent with nerve root compression

- Medical "red flags" of a potentially serious condition including cauda equina
syndrome, major or rapidly progressing neurological deficit, fracture, cancer,
infection, or systemic disease