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Re: Criterion and Mechanisms for Lumbar Facet Joint Pain
Criterion and Mechanisms for Lumbar Facet Joint Pain
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Viktoria Eugenie Wilde, Physiotherapist Author, Joan M McMeeken
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v.wilde{at}pgrad.unimelb.edu.au Viktoria Eugenie Wilde, et al.
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Dear Ms Renee Strobl We thank you for your detailed and considered response to our article. We believe that further discussion and research into LZJ pain is indicated. As mentioned, the experts provided pathoanatomical justifications for each of the indicators of LZJ pain; however, your detailed clarification of the complex mechanisms of LZJ pain generation is appreciated. Your response emphasizes the complexity of damage to the LZJs and reinforces that simplistic therapeutic interventions must be very carefully considered. We look forward to further research into this pathoanatomical subgroup of low back pain. Sincerely, Viktoria E Wilde |
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Renee M. Strobl, physical therapist Beaumont Hospital-Grosse Pointe, outpatient rehabilitation, St. Clair Shores, Michigan
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r.strobl{at}comcast.net Renee M. Strobl
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I commend the authors on utilizing the collaboration of the medical and physical therapy professions in an attempt to seek common ground with respect to this less-than-definitive clinical entity. Table 3 (Evidence-Based Justification for Indications of Lumbar Zygapophyseal Joint Pain), number 11, "Pain in extension, lateral flexion, or rotation to the ipsilateral side," mentions that “maximal compression of LZJ [lumbar zygapophyseal joint] surfaces occurs with these movements.” However, with respect to rotation, the lumbar facet receiving compressive loads is the contralateral facet, or the facet on the side opposite the direction of rotation (eg, the left facet with right rotation).[1] The load occurring at the ipsilateral lumbar facet is tensile (the left facet with left rotation).[1] Therefore, pain at the ipsilateral facet with rotation may be due to hypertrophy of the facet, allowing for stretch of the joint capsule,[2] traction of a fibrotic capsule adhered to the cartilage surface, or traction of fibrotic synovial folds adhered to neural structures.[3] Furthermore, the research by Yang and King[4] mentioned by the authors does not explore compression with lateral flexion or rotation but only compressive loading of the lumbar facet in extension. Interestingly, their proposed mechanism of low back pain involves stretching to the lumbar facet capsule under high loads in extension due to the fulcrum effect of the inferior spinous process on the pars interarticularis of the vertebrae below and not necessarily due to the compression through the facet itself. However, compression of subchondral bone of the lumbar facet may be the source of low back pain.[2,5] Despite the experts in the study and not the authors providing justification for indicators of LZJ pain, it is necessary to make these points for future discussion and research on clinical signs and symptoms of LZJ pain and its proposed mechanisms. References 1 Shirazi-Adl A. Nonlinear stress analysis of the whole lumbar spine in torsion-mechanics of facet articulation. J Biomech. Mar 1994;27:289- 299. 2 Beaman DN, Graziano GP, Glover RA, et al. Substance P innervation of lumbar spine facet joints. Spine. 1993;18(8):1044-1049. 3. Giles GF, Harvey AR. Pathoanatomic studies and clinical significance of lumbosacral zygapophyseal (facet) joints. J Manipulative Physiol Ther. Jan 1992;15:253-256. 4. Yang KH, King AI. Mechanism of facet load transmission as a hypothesis for low-back pain. Spine. 1984;9:557-565. 5. Dunlop RB, Adams MA, Hutton WC. Disc space narrowing and the lumbar facet joints. J Bone Joint Surg Br. Nov 1984;66:706-710. |
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