THE ROLE OF THE ILIOPSOAS MUSCLE COMPLEX IN CHRONIC SPINAL PAIN AND ASSOCIATED SIGNS AND SYMPTOMS By Aileen S. Jefferis Diploma of Physiotherapy NZ (1976) Graduate Diploma Social Sciences-Rehabilitation University of South Australia (2000) This thesis is presented as a requirement for the degree of Doctor of Philosophy in the Department of Physiotherapy, Faculty of Medicine, Nursing, and Health Sciences at Flinders University, South Australia. TABLE OF CONTENTS………………………………………………………..i Chapter One………………………………………………………………………i Chapter Two……………………………………………………………………..ii Chapter Three…………………………………………………………..………iii Chapter Four……………………………………………………………………iii Chapter Five…………………………………………………………………….iii Chapter Six………………………………………………………………….......iv Chapter Seven…………………………………………………………………...v References……………………………………………………………………......v Appendices……………………………………………………………………....v Consort flow diagrams………………………………………………………….v Diagram…………………………………………………………………………vi Figures……………………………………………………………………….….vi List of tables…………………………………………………………………....vii X-rays…………………………………………………………………................ix Abbreviations……………………………………………………………………x Definition of chronic low back pain as uses in this used in this research.......xi Reasons for tense utilisation..……………………………………….….….…..xi Summary of this thesis……………………………………………………......xiii Statement of authorship……………………………………………….……..xvii Dedication……………………………………………………………..….........xix Acknowledgments……………………………………………………...............xx CHAPTER ONE: Contextual preface…………………………………………1 1.1 Clinical experience ....................................................................................... 1 1.2. Case Studies .................................................................................................. 2 1.2.1 Case Study One: .......................................................................................... 2 1.2.2 Case Study Two: ......................................................................................... 6 i 1.2.3 Case Study Three: ....................................................................................... 9 1.2.4 Case Study Four: ...................................................................................... 11 1.2.5 Case Study Five: ...................................................................................... 133 1.2.6 Case Study Six: .......................................................................................... 14 1.3 Discussion ................................................................................................... 16 CHAPTER TWO: Introduction to chronic low back pain ........................... 18 2.1 Background to chronic low back pain ..................................................... 18 2.2 Definitions of pain ...................................................................................... 19 2.3 Definitions of low back pain and chronic low back pain ....................... 20 2.4 Estimates of the incidence of chronic low back pain .............................. 22 2.5 Financial and psycho-social costs of chronic low back pain .................. 23 2.6 Anatomical structures of the spine relevant to potential causes of chronic low back pain and chronic spinal pain ....................................... 24 2.7 Treatment approaches for chronic low back pain .................................. 30 2.7.1 Invasive treatments for chronic low back pain………………………..30 2.7.2 Non-invasive treatments for chronic low back pain and chronic spinal pain……………………………………………………………….. 37 2.8 Myofascial trigger points ……………..................................................... 42 2.8.1 Introduction to myofascial trigger points ............................................... 42 2.8.2 Hypotheses of mechanisms of causation and aetiology of myofascial trigger points………………………………………………………..…...43 2.8.3 Clinical relevance of myofascial trigger points……………………..….49 2.8.4 Classifications and clinical manifestations of myofascial trigger points……………………………………………………………….…….52 2.8.5 Treatments of myofascial trigger points……………………………….55 2.8.6 Perpetuating factors of myofascial trigger points……………………..58 ii 2.9 Conclusion………………………………………………………………..60 CHAPTER THREE: The iliopsoas muscle complex………………………..61 3.1 Introduction to the iliopsoas muscle complex..…………………………61 3.2 Anatomical composition and considerations of the iliopsoas muscle complex…………………………………………………………………..61 3.3 Actions and functions of the iliopsoas muscle complex………………...68 3.4 The potential participation of the iliopsoas muscle complex on intradiscal pressures and disc pathology…………………………….…75 3.5 The potential role of the iliopsoas muscle complex in chronic low back pain………………………………………………………………….75 3.6 Potential myofascial trigger point sites and pain patterns of the iliopsoas muscle complex…………………………………………………77 3.7 Stretching protocols for the iliopsoas muscle complex…..……………..78 3.8 Summary ………………………………………………………………….79 CHAPTER FOUR: Systematic review of the literature on treatment of myofascial trigger points in people with chronic low back pain……....81 4.1 Search method…………………………………………………………….81 4.2 Inclusion criteria………………………………………………………….81 4.3 Results of systematic search one…………………………………………83 4.4 Results of systematic search two………………………………………....85 4.5 Summary……………………………………...………………………….. 89 CHAPTER FIVE: The participation of the iliopsoas muscle complex in chronic low back pain and chronic spinal pain…..………………………....90 5.1 Introduction……………………………………………………………….90 5.2 Study methods…………………………………………………………….90 iii 5.2.1 Ethical requirements and undertakings………………………………90 5.2.2 Sample size………………………………………………………….…..91 5.2.3 Criteria……………………………………………………………….…92 5.2.4 Recruitment………………………………………………………….…93 5.2.5 Initial baseline assessment and randomisation into intervention and stretching groups…………………………………………………..94 5.2.6 Procedure: intervention group………………………………………...96 5.2.7 Procedure: stretching group…………………………………………...97 5.2.8 Outcome assessment………………………………………………........99 5.3 Data analyses………………………………………………………......100 5.4 Results…………….……………………………………….……...…....100 5.5 Summary……………………………………………………………….126 CHAPTER SIX: The role of the iliopsoas muscle complex in associated signs and symptoms in chronic low back pain and chronic spinal pain…128 6.1 Abstract………………………………………………………………….128 6.1.1 Objectives...............................................................................................128 6.1.2 Method……………………………………………………...………….128 6.1.3 Results………………………………………………………………….129 6.1.4 Conclusions…………………………………………………………….129 6.2 Introduction………..……………………………………………….......129 6.3 The aim of the study………………………………………………...….130 6.4 Zinc….......................................................................................................130 6.4.1 Zinc measurement………………………………..................................131 6.4.2 Signs and symptoms of zinc deficiency………………………….…....133 6.5 Depression and Anxiety………………………………………………..136 6.6 Gastrointestinal Dysfunction………………………………………....138 iv 6.6 Urinary Dysfunction…………………………………………..………139 6.7 Summary of the literature findings……………………………..........139 6.8 Method…………………………………………………………..…......139 6.8.1 Ethical requirements and undertakings…………………………..…139 6.8.2 Sample Size……………………………………………………………140 6.8.3 Criteria………………………………………………………………...141 6.8.4 Recruitment…………………………………………………………...142 6.8.5 Procedure………………………………………………………...……142 6.8.5 Data analyses……………………………………………………..…...144 6.9 Results.………………………………………………………………...144 6.9.1 Zinc findings………………………………………………………….144 6.9.2 Myofascial trigger point findings………………………………...….148 6.9.3 Depression, anxiety/agitation, mood swings, impaired concentration, word finding difficulties/word transposition………151 6.9.4 Gastrointestinal findings......................................................................152 6.9.5 Urinary findings…………………………………………………..…..153 6.10 Summary………………………………………………………...……153 CHAPTER SEVEN: Summation………………………………..…...……155 7.1. Discussion………………………………………………………...……155 7.2. Limitations of this research……………………………………...…...158 7.3. Implications for policy and practice……………………………...….159 7.4. Conclusion……………………………………………………………..163 REFERENCES:…………………………………………………….…...….165 APPENDICES:...............................................................................................217 1. Study Five: Ethics Application.................................................................217 2. Study Five: Ethics Approval.....................................................................227 v 3. Study Five: Inclusion, exclusion, and withdrawal criteria.....................228 4. Study Five: Letter to private practitioners..............................................229 5. Study Five: Participants Information sheet.............................................230 6. Study Five: Consent form..........................................................................232 7. Study Five: Patient History Questionnaire..............................................233 8. Study Five: Short-form McGill Pain Questionnaire...............................234 9. Study Five: Patient Specific Disability Measure.....................................235 10. Study Five: Stretching diary...................................................................236 11. Study Five: Blinded Outcome Assessment form...................................237 12. Study Six: Ethics application..................................................................238 13. Study Six: Ethics approval......................................................................243