ARTICLE INFO

Article Type

Descriptive & Survey Study

Authors

Faraji   E. (1)
Barati   A.H. (2)
Fateh   H.R. (3)
Allami   M. (*)






(*) Department of Medical & Rehabilitation Devices, Janbazan Medical and Engineering Research Center (JMERC), Tehran, Iran
(1) Sport Injuries & Corrective Exercise Department, Physical Education and Sport Sciences Faculty, Kharazmi University, Tehran, Iran
(2) Sport Injuries & Corrective Exercise Department, Physical Education & Sport Sciences Faculty, Shahid Beheshti University, Tehran, Iran
(3) Physical Medicine & Rehabilitation Department, Medicine Facult, Tehran University, Tehran, Iran

Correspondence

Address: Janbazan Medical and Engineering Research Center (JMERC), No. 17, Farokh Street, Moghadas Ardabili Street, Yaman Street, Shahid Chamran Highway, Tehran, Iran
Phone: +98 (21) 22172424
Fax: +98 (21) 22418180
iranassistive@gmail.com

Article History

Received:  April  12, 2017
Accepted:  May 23, 2017
ePublished:  November 6, 2017

BRIEF TEXT


… [1]. Secondary musuloskeletal disorders in lower limb amputees include those with upper limb amputation and those with lower limb amputation [2]. In particular, chronic non-specific back pain is a major secondary disorder, with an incidence of over one month between 50 to 80% [3, 4].

… [5, 6]. Previous studies have shown that pain back in people with lower limb amputation is multifactorial in character and generally classified into individual, psychosocial and physical factors (biomechanics) [7, 8]. … [9-14]. Although the causes of back pain are not well known, research findings suggest that changes in the strategies of muscular, biomechanical and motor recall strategies toward degenerative factors is more effective in back pain in lower limb amputees [4, 15].

The aim of this study was to investigate the factors related to the severity of back pain in unilateral amputees suffering from chronic back pain.

This study is a descriptive-correlational one.

This research was carried out in 2016 among 175 sub-knee amputees who participated in the design of health assessment of unilateral under knee amputees of Tehran in the Orthotic and Prosthetic Kosar Center.

62 men veterans with back pain were selected through convenience sampling method and participated in the research. Inclusion criteria were the age range of 35 to 60 years, unilateral under knee amputation, a back pain that lasted 12 weeks or more and continued use of the prosthesis. Exit criteria included the presence of Red flag in the evaluation of back pain according to the opinion of the expert physician and the unwillingness of the individual to participate in the evaluation of electromyography.

Demographic evaluations and disorders were performed using interviews with veterans. To assess the severity of back pain and its related factors, the following evaluations were performed: A) Assessment of the severity of back pain and disability caused by back pain: the severity of pain was evaluate at the time of study, in the best and worst case during the last three months with numerical pain rating scale (NPRS). A zero score indicates a lack of pain. 1-4 indicates mild pain; 5-6 indicates moderate pain and 7-10 indicates severe pain [16]. Oswestry Disability Index (ODI) was also completed by the participants to measure the disability level of the participants. The total disability index is evaluated between zero and 100. Higher scores means more disability. A score of 0-21%, 41-60%, 61-80%, and 81-100% indicate mild disability, moderate disability, severe disability, and the most significant functional disorder associated with back pain that is the person is limited by hospitalization, respectively [17]. …[17-19]. B) Biomechanical evaluation: the activity of different muscles behind the body was indirectly measured by surface electromyography as a gold standard for muscle function [20-22]. Maximal contraction of the lumbar spinoconstrictor muscle and superficial muscle fibers of the lumbar spinal muscle were recorded by conducting trunk extension against a manual resistor. Maximal voluntary contraction of the muscles was accomplished through a series of manual contractions. Maximum voluntary contraction was done for extensor muscles of the spine with resistance to extension of the trunk. People are placed in the abdomen and attempted to open the spine from the back against implemented resistance by the examiner [23-25]. Each contraction was performed 3 times with a 30-second rest period to remove fatigue. In order to record the electrical activity, the electrodes were placed on the bulk of muscles on the amputee side and healthy side. The electrodes were placed on the surface of the muscle of the lumbar polyphidose muscle 2 cm outside the spinous process of L4 and for the lumbar spinach spine 5 cm out of the spinous process of L2 [26, 27]. The reference electrode was placed on the osteoarthritis of Olena. Electromyography recording was performed using 8-channel EMG (Wireless V8.24, BayaMed, Iran) and F-55 Model electrodes (Skintact, Austria). 1000 Hz frequency sampling rate, analog-to-digital conversion with 16-bit A/D converter and passband filter of 20 to 300 Hz were carried out. Data analysis was performed in the Lab view using BayaMed software. The root mean square (RMS) was considered as the most significant signal strength measurement and the mean scores of 3 times of the contractions were finally recorded. The symmetry coefficient of activity of mulifidus and Erector spinae muscles of the healthy side and amputee sides were calculated using the formula. The symmetry coefficients of near zero and near100 indicate low and high asymmetry respectively [28]. The type of prosthesis, sock and paw were recorded and clinical evaluations were performed by exports to determine the fitting or unsuitability of socket fitting, prosthetic height, static strength, and dynamics of the prosthesis. Data analysis was done using SPSS 20 software. Kolomogronov-Smirnov test was used to check the normal distribution of data. Pearson correlation coefficient and Spearman correlation coefficient were used to determine the correlation between variables. Simple linear regression analysis was used to predict the criterion variable (pain intensity) based on predictive variable (muscle asymmetry). The chi-square test was also used to investigate the relation between constraint and stamping length.

The percentage of injuries was 35-70% and all of these people had used prosthesis (Table 1). 11 (17.7%), 33 (53.2%), and 17(27.4%) of the veterans had mild, moderate, and severe disability respectively and only one (1.6%) were completely impotent. Also, 14(23.0%) could walk easily and without any pain and 10 (16.4%) of the veterans could stand without time limit (Table 2). The multiphidosis muscle asymmetry coefficient had a significant relationship with the time of use of prosthesis per day (p=0.04; r=0.23) and the asymmetry of Erector spinae muscle had significant relationship with the years of using prosthesis (p=0.03; r=0.26). The mean of asymmetric coefficient of multifidus muscle with back pain, also, showed a significant relation (p=0.01; r=0.31). However, this relation was not significant for Erector spinae muscle (p=0.3). The multifidus muscle asymmetry coefficient could explain the intensity of pain with coefficient of determination of 0.09 (p<0.05). Fitting socket, prosthetic height, static echolation, and dynamic etiquette were inappropriate in 20 (3.32%), 9(14.5%), 10 (16.1%), and 19(30.6%) of the participants. Also, 38(60.7%) did not use any aids inside or outside of the home. There was no significant correlation between the length of stamp and the intensity of back pain. There was no significant relationship between limitation in walking and the length of stamp (p>0.05; Table 3). There was no significant correlation between age and body mass index. However, history of smoking (p=0.04; r=0.21), psychiatric disorders (p=0.02; r=-0.25), the height of prosthesis (p=0.04; r=0.21) and the use of helping device (p=0.03; r=0.27) had significant correlation with back pain intensity (Table 4).

… [29-39]. In this study, the severity of back pain was significantly associated with inappropriate prosthetic height. In a study, it was showed that people with lower extremity amputation with severe and permanent back pain had significantly greater difference in the length of limbs than those who had occasional back pain [40]. However, these results have not been confirmed in similar studies [15, 41]. Changes in the lumbar-pelvis kinematic were secondary as a result of the difference in the length of the two limbs (more than 30 mm) during the performance of the function of individuals under the knee amputation [42]. The contradictory results can be due to difference in the method of measuring the length difference between two organs and the characteristics of the studied population. There is a need for further studies with the aim of investigating the relationship between the length of two limbs and back pain. The history of smoking was associated with an increase in pain intensity, which was also confirmed in another study [7]. Studies that have investigated the effect of socio-psychological factors on the occurrence or remain of back pain in people with lower limb amputations, are limited. In a new survey in under knee amputees, there was a significant correlation between depressive state and reporting of pain [4]. The results of a study provided early evidence of the association between psychosocial factors (such as suffering, depression, anxiety, and related factors of work) and back pain in amputee group [43].

It is suggested that higher sample size be considered in future studies. Also, different design studies based on examining exercises and therapeutic movements seem necessary to reduce muscle asymmetry.

Of the limitations of this study was a small sample size.

Muscular asymmetry because of using prosthesis, prosthesis height, neurological and psychological damage, and smoking are factors associated with back pain intensity in unilateral amputations under the knee.

Thanks to all the friends and veterans who participated in this research.

Non-declared

The ethics committee in the Biomedical Researches in Foundation of Martyrs and Veterans Affairs confirmed this research with code D-E-95-103. For the subjects in the study, the consent form was distributed and collected and the information was kept confidentially.

The cost of this project has been provided by Research and Engineering Institute of Foundation of Martyrs and Veterans Affairs in Tehran, Iran.

TABLES and CHARTS

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