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Mesotherapy versus Systemic Therapy in the Treatment of Acute Low Back Pain:

A Randomized Trial
Cosimo Costantino,1,* Emilio Marangio,2 and Gabriella Coruzzi3
1Department of Surgical Sciences, Section of Orthopedy, Traumatology and
Functional Rehabilitation, University of Parma, 43121 Parma, Italy
2Department of Clinic Sciences, Section of Respiratory Physiopathology,
University of Parma, 43121 Parma, Italy
3Department of Human Anatomy, Pharmacology and Forensic Medicine,
University of Parma, 43121 Parma, Italy
*Cosimo Costantino: Email: ti.rpinu@onitnatsoc.omisoc
Author information Article notes Copyright and License information
Received April 9, 2010; Revised June 24, 2010; Accepted August 7, 2010.
Copyright 2011 Cosimo Costantino et al.
This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
This article has been cited by other articles in PMC.
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Pharmacological therapy of back pain with analgesics and anti-inflammatory
drugs is frequently associated with adverse effects, particularly in the elderly.
Aim of this study was to compare mesotherapic versus conventional systemic
administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and
corticosteroids in patients with acute low back pain. Eighty-four patients were
randomized to receive anti-inflammatory therapy according to the following
protocols: (a) mesotherapy group received the 1st and 4th day 2% lidocaine (1
mL) + ketoprofen 160 mg (1 mL) + methylprednisolone 40 mg (1 mL), then on
7th, 10th, and 13th day, 2% lidocaine (1 mL) + ketoprofen 160 mg (1 mL) +
methylprednisolone 20 mg (1 mL) (b) conventional therapy group received
ketoprofen 80 mg 2/die and esomeprazole 20 mg/die orally for 12 days,
methylprednisolone 40 mg/die intramuscularly for 4 days, followed by
methylprednisolone 20 mg/die for 3 days, and thereafter, methylprednisolone 20
mg/die at alternate days. Pain intensity and functional disability were assessed at
baseline (T0), at the end of treatment (T1), and 6 months thereafter (T2) by
using visual analogic scale (VAS) and Roland-Morris disability questionnaire
(RMDQ). In both groups, VAS and RMDQ values were significantly reduced at the
end of drug treatment and after 6 months, in comparison with baseline. No
significant differences were found between the two groups. This suggests that

mesotherapy may be a valid alternative to conventional therapy in the treatment

of acute low back pain with corticosteroids and NSAIDs.
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1. Introduction
Low back pain affects a high proportion of adult population in the developed
countries and has a major impact on health care system and society [1, 2].
Conventional pharmacological therapy to reduce pain, inflammation, and
functional disability usually relies upon the extensive use of nonsteroidal antiinflammatory drugs (NSAIDs), paracetamol (acetaminophen), corticosteroids, and
various opioids. However, the major drawback of pharmacological therapy with
analgesics and anti-inflammatory drugs is the frequent association with adverse
effects [3]; in particular, NSAID-related toxicity is connected to the inhibition of
constitutive prostaglandins (PGs), with consequent impairment of gastric
mucosal defense and renal homeostasis [4]. On the other hand, the availability
of selective cyclooxygenase-2 (COX-2) inhibitors (Coxibs), despite providing a
reduction in the gastrointestinal toxicity, resulted in a high risk of developing
serious cardiovascular and renal side effects [5, 6]. Chronic therapy with
systemic corticosteroids may afford a variety of serious untoward reactions,
leading to hypertension, diabetes, glaucoma, gastric ulcer, osteoporosis, and
psychiatric disorders [7, 8]. Finally, opioids, used either alone or in combination
with paracetamol and/or NSAIDs, may cause a variety of side effects which are
dose-limiting and reduce quality of life, bowel dysfunction being one of the most
common and persisting problems [9]. Thus, new therapeutic options endowed
with comparable efficacy and better safety are warranted.
Among the various attempts to reduce drug toxicity, the use of local therapy
(neural block, intraarticular, or periarticular injections of corticosteroids) has
gained popularity among physicians [10, 11], despite some controversies
concerning its efficacy as a therapeutic remedy [12].
During the last decades, researchers and patients have become increasingly
interested in complementary and alternative medicine (CAM) as a possible mean
to ensure efficacy, while improving therapeutic safety [1315]. Back pain, in
particular, is the most common reason for CAM use both in Europe and USA [15].
However, despite the large favour by the general population and several
published clinical studies, only few physical treatments are supported by strong
scientific evidence [1618]; likewise, controlled clinical studies evaluating the
effectiveness of the most popular CAM therapies used for low back pain are still
scarce [19], very few mechanistic studies are available [20, 21], the quality of
research is generally poor, and general conclusions are difficult to reach [16].
Mesotherapy was introduced 50 years ago by Michel Pistor, a French physician
who utilized this technique as a novel analgesic therapy for a variety of
rheumatologic disorders [22]. Mesotherapy is a minimally invasive technique
that consists of subcutaneous injections of drugs and, occasionally, plant
extracts, homeopathic agents, or other bioactive substances; for this reason, it

has been often considered a CAM, rather than a conventional medical therapy
[23, 24]. Since its introduction, the use of mesotherapy has been expanded, and
therapeutic indications have increased; although most applications are found in
osteoarticular pathologies [2528], over the recent years, this technique has
become popular in cosmetic medicine for the treatment of cellulite and fat
deposition [29, 30].
Based on these premises, the following study was designed to evaluate the
effectiveness of anti-inflammatory drugs (NSAIDs and corticosteroids)
administered via mesotherapy in comparison with conventional systemic therapy
by oral and intramuscular route, for the treatment of acute low back pain.
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2. Methods
The study was carried out at the Department of Physical Medicine and
Rehabilitation of the University of Parma following the guidelines for
experimental investigation with human subjects required by the local University.
Informed written consent was obtained from each patient.
2.1. Patient Recruitment
Patients were recruited for the study from the Emergency Department between
January and May 2007 and checked for eligibility by the clinical investigator.
Patients were enrolled into the study, provided that they had been suffering from
back pain since no more than 2 weeks and reported a current pain intensity >65
on a 100 mm visual analogic scale (VAS). Exclusion criteria were represented by
diabetes, anticoagulant therapy, or pregnancy. Patients were also excluded if
they had evidence of cardiovascular, renal, hepatic, gastrointestinal, or
psychiatric diseases. Eighty-four patients (44 men, 40 women) aged 2477 years
and suffering from acute low back pain, with cruralgia or sciatalgia were included
into the study. Patients could leave the study at any time for any reason.
2.2. Study Design
Patients who met the eligibility criteria were randomly allocated to receive antiinflammatory therapy with NSAIDs (ketoprofen) and corticosteroids
(methylprednisolone, MP), administered either by mesotherapic technique or by
oral/intramuscular route, according to the study plan described in Figure 1.

Figure 1
Study design and drug treatment.

Drug regimen employed in group A (22 men, 20 women) was as follows: 2%

lidocaine (1 mL) + ketoprofen 160 mg (1 mL) + MP 40 mg (1 mL) at day 1 and 4,
then 2% lidocaine (1 mL) + ketoprofen 160 mg (1 mL) + MP 20 mg (1 mL) at day
7, 10, and 13. Five repeated injections (3 mL for each injection) were
administered at inter and paravertebral level along the running of sciatic nerve,
through specific needles (30 G 4 mm), which were inserted deeply for the
whole lenght (Figure 2). Lidocaine was used to minimize pain at site of injection.

Figure 2
Injection points of a single mesotherapic treatment. Drug injections were
administered along the running of sciatic nerve, through specific needles (30 G
4 mm) (see Methods, for details).
Group B (22 men, 20 women) received drug therapy according to the following
protocol: ketoprofen 80 mg X2/die orally for 12 days; MP intramuscularly 40
mg/die for the first 4 days, then 20 mg/die for 3 days, then 20 mg/die at alternate
days. Patients of this group received esomeprazole 20 mg/die for 12 days, as
gastroprotective therapy.
2.3. Outcome Measures
Self-rated pain intensity was assessed by using the VAS scale (0 = no pain, 100
intolerable pain), a horizontal, unmarked 100 mm scale widely validated to
assess pain [31]. Functional disability in the daily life activity was measured by
the Roland-Morris disability questionnaire (RMDQ) (varying score from 0 to 24).
Both parameters were evaluated at baseline (T0), at the end of the drug
treatment (12 days, T1), and at 6 months thereafter (follow up, T2) by two
independent observers blind to the pharmacological treatment.
2.4. Statistical Analysis
All quantitative data were entered into a specifically designed database (SPSS V
17.01). Chi-Square Mann-Whitney and Kolmogorov-Smirnov test were employed
to evaluate the omogeneity of the groups, as for sex or age, respectively.
Wilcoxon signed rank test was utilized to analyze the variations among values
obtained at baseline (T0), end of treatment (T1), followup (T2), and T0-T1, T1-T2;
Krusall-Wallis test was used to analyze differences among T0-T1-T2. F test was
employed for variance analysis and T test for independent data. A P value < .05
was considered statistically significant.
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3. Results
3.1. Patient Characteristics
A total of 84 patients were enrolled into the study. All treated groups were
balanced with respect to demographic and baseline characteristics (Table 1). In
particular, the patient distribution between the groups was comparable as for
sex and age, scores for pain (VAS), and functional disability (RMDQ).

Table 1
Baseline characteristics of patients.
3.2. Pain and Functional Disability
In group A (mesotherapy), VAS and RMDQ scores were significantly reduced at
the end of the pharmacological treatment (P < .0001) whereas after 6 months
only VAS score was still significantly different from baseline (P = .04) (Figure 3).
In group B (conventional pharmacotherapy), VAS and RMDQ were significantly
reduced at the end of the treatment (P < .0001 and P < .001, resp.) and both
scores were still significantly different from baseline after 6 months (P = .673 and
P = .400, resp., versus data at the end of drug administration) (Figure 4).
Mesotherapy was well-tolerated and local or allergic reactions were not
observed. Minimal pain during and after injection was prevented by the local
anaesthetic. Transient bleeding and signs of inflammation occurred in patients at
the site of injection, but they resolved in a few days.

Figure 3
Effect of anti-inflammatory drugs on the reduction of pain, as measured by visual
analogic scale (VAS) in patients with acute low back pain. Drug treatment was
done either via mesotherapy or via standard systemic route of administration
(see methods ...

Figure 4
Effect of anti-inflammatory drugs on the reduction of functional disability, as
measured by Roland-Morris disability questionnaire (RMDQ), in patients with
acute low back pain. Drug treatment was done either via mesotherapy or via
standard systemic route ...
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4. Discussion
The aim of this study was to evaluate the effectiveness of anti-inflammatory
drugs administered via mesotherapy in patients with acute low back pain.
Present results showed for the first time that the administration of NSAIDs and
corticosteroids via mesotherapic technique can provide the same therapeutic
benefit as that induced by conventional (oral and intramuscular) drug
administration. Indeed, both treatments significantly reduced pain intensity and
disability in daily life activity, and the effect was maintained up to 6 months.
These results are in accordance with previous studies showing that naproxen and
diclofenac, administered via mesotherapy, were more effective than after oral
administration [27, 32, 33].
The major finding of this study is the comparable effectiveness of mesotherapy
and conventional systemic therapy, despite the lower amount of drugs
administered to patients undergoing mesotherapy (41,67% ketoprofen and 50%
methylprednisolone) (Figure 5). The comparable efficacy of mesotherapy and
conventional therapy, despite different drug dosages, is difficult to explain.
Subcutaneous drug administration results in a very slow drug absorption in
comparison with other systemic routes, such as oral and intramuscular; thus it
could be hypothesized that anti-inflammatory drugs, administered via
mesotherapy, achieve a high drug concentration into the subcutaneous tissue
and exert local effects in close proximity to inflammatory cells, sensory fibers,
and vascular mediators that orchestrate inflammation and pain.

Figure 5
Therapeutic outcome of mesotherapy in comparison with conventional systemic
therapy for acute low back pain. These two routes of administration resulted in
comparable efficacy, despite the lower (approximately 50%) total amount of drug
administered via ...

Although no measurement was made in our study of drug plasma levels after the
two routes of administration, it is presumable to hypothesize that mesotherapic
treatment resulted in a lower systemic bioavailability of drugs, with consequent
lower incidence of adverse reactions. This could offer a great therapeutic
advantage, when considering the high rates of adverse effects, associated with
NSAID or corticosteroid use in the elderly population [3, 4, 7]. While the use of
proton pump inhibitors has significantly limited the incidence of peptic ulceration
and other acid-related disorders [34], renal and cardiovascular problems still
remain of particular concern. In this connection, both nonselective and COX-2selective NSAIDs were found to reduce glomerular filtration, increase fluid
retention and blood pressure [5, 6], and some highly selective COX-2 inhibitors
were found unfavourable in patients with cardiovascular diseases and were
withdrawn from the market [5, 35]. Corticosteroids, on the other hand, may have
a variety of side effects, including hypertension, diabetes, osteoporosis,
glaucoma, and peptic ulcer, which are dose-dependent and related to the
systemic drug availability [7, 8].
Although mesotherapic techniques used in dermatologic surgery have been
associated with a number of adverse effects at sites of injection, including
atypical mycobacterial infections [36], urticaria [37], lichenoid drug eruptions
[38, 39], and psoriasis [40], no evidence of local reactions were found in the
present study.
In conclusion, results of the study indicate that combined administration of
conventional NSAIDs and corticosteroids by mesotherapy is an effective and welltolerated method for managing low back pain in the short-term, compared with
drug therapy administered by oral and intramuscular route. Possible weaknesses
of our study are the small number of patients, the short followup period, and the
lack of drug plasma level measurements. However, if confirmed in a large trial,
these observations could be of potential interest in the pharmacological
treatment of low back pain to reduce the adverse effects associated with high
plasma levels of antiinflammatory drugs.
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The authors wish to thank Maurizio Agosti for helping in data analyses and Mrs.
Sara Maxwell Scott for revising the language. This study was supported by a
grant from the Dept Surgical Sciences Section of Orthopedy, Traumatology and
Functional Rehabilitation, University of Parma. There was no financial assistance
with the project. There is no potential conflict of interest existing with respect to
the authors of this paper. The study gained the approval from the University of
Parma Ethics Committee.
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1. Introduction
2. Methods
3. Results
4. Discussion

J Phys Ther Sci. Dec 2013; 25(12): 15411545.

Published online Jan 8, 2014. doi: 10.1589/jpts.25.1541
PMCID: PMC3885835

The Effects of Stabilization and Mckenzie

Exercises on Transverse Abdominis and
Multifidus Muscle Thickness, Pain, and
Disability: A Randomized Controlled Trial
in NonSpecific Chronic Low Back Pain
Mohammad Hosseinifar, PhD Candidate,1 Mohammad Akbari, PhD,1,* Hamid Behtash, MD,2
Mohsen Amiri, PhD,3 and Javad Sarrafzadeh, PhD1
Author information Article notes Copyright and License information
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[Purpose] This study compared the effectiveness of stabilization and McKenzie exercises on
pain, disability, and thickness of the transverse abdominis and multifidus muscles in patients
with nonspecific chronic low back pain. [Subjects] Thirty patients were randomly assigned
into two groups: the McKenzie and stabilization exercise groups. [Methods] Before and after
intervention, pain, disability, and thickness of the transverse abdominis and multifidus
muscles were evaluated by visual analogue scale, functional rating index, and sonography,
respectively. The training program was 18 scheduled sessions of individual training for both
groups. [Results] After interventions, the pain score decreased in both groups. The disability
score decreased only in the stabilization group. The thickness of the left multifidus was
significantly increased during resting and contracting states in the stabilization group. The
thickness of the right transverse abdominis during the abdominal draw-in maneuver, and
thickness of the left transverse abdominis during the active straight leg raising maneuver
were significantly increased in the stabilization group. The intensity of pain, disability score,
thickness of the right transverse abdominis during the abdominal draw-in manouver, and
thickness of the left transverse abdominis during active straight leg raising in the stabilization
group were greater than those on the Mackenzie. [Conclusion] Stabilization exercises are
more effective than McKenzie exercises in improving the intensity of pain and function score
and in increasing the thickness of the transverse abdominis muscle.
Key words: Chronic low back pain, Stabilizaton exercises, Muscle thickness
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Lack of spinal core stability is supposed to be one of the important predisposing causes of
recurrent low back pain (LBP)1). As a result, more attention has been paid to training of
localized spinal stabilizer muscles in subjects with LBP2). It is believed that specific

stabilization exercises lead to changes in motor programing of the automatic feed-forward

recruitment of deep core muscles3). Therefore, stabilization exercises were suggested for
chronic low back pain (CLBP) patients4,5,6,7).
Recently, it has been reported that the use of stabilization exercises can improve the
multifidus (MF) muscle size in acute LBP2). However, few studies have reported the impacts
of stabilization exercises on the size and function of stabilizer muscles8, 9). One study reported
that the stabilization exercises led to an increase in the thickness of the stabilizer muscles8).
Another study showed borderline changes in contracting thickness of the TrA muscle
following application of stabilization exercises9). As a result, there is a lack of sufficient
objective evidence about the effects of stabilization exercises on the thickness of the stabilizer
muscles, especially thickness when contracted. Another approach is the McKenzie method10).
This approach is focused on sustained postures or repeated movements11). Although
McKenzie exercises could improve pain intensity in acute low back pain, subacute low back
pain and CLBP12), no study with regard to the effect of McKenzie exercises on the thickness
of the stabilizer muscles in CLBP was found in a review of the literature.
As mentioned above, this study was carried out to determine and compare the effectiveness of
stabilization and McKenzie exercises on pain, disability and TrA and MF muscle thickness in
resting and contracting states in patients with nonspecific CLBP. It was hypothesized that
stabilization exercises would increase the thickness of TrA and MF muscles and that
McKenzie exercises would not have any effects on the thickening of the TrA and MF
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In this single randomized controlled trial study, the participants were selected through a
simple non-probability sampling method and were randomly divided into two equal groups
using sequences of random numbers. The first group (n=15) performed stabilization
exercises, and the second group (n=15) performed McKenzie exercises. The examiner who
assessed the outcomes was blinded to group assignment. The training program consisted of
18 sessions of supervised individual training for both groups, with the sessions performed 3
times per week for 6 weeks. Each training session lasted an hour and was performed at the
Physiotherapy Clinic in the School of Rehabilitation, Tehran University of Medical Sciences,
Tehran, Iran, between 2011 and 2012. Outcomes were measured in both groups before and
after treatments. The study protocol was approved by the ethics committee of Tehran
University of Medical Sciences. All patients provided written informed consent to participate
in the study.
Thirty patients with nonspecific CLBP participated in this study on the basis of a clinical
examination performed by a physician and the following inclusion criteria: age between 18
50 years, CLBP in the area between the costal margin and buttocks, with or without reference
to the lower extremity (no radicular pain) that lasted more than 3 months. Patients were
excluded if they had a history of recent fracture, trauma or previous surgery in the lumbar
region; had spondylolysis or spondylolisthesis, spinal stenosis, neurological disorders,
systemic diseases, cardiovascular diseases, diseases; were pregnant; were receiving

concomitant treatment, with physical therapy modalities; or were receiving other therapies
simultaneously7, 13).
After referral by a specialist, patients were reviewed based on the inclusion and exclusion
criteria. Then demographic characteristics including age, sex, height, and weight were
collected using a questionnaire. The pain history including the onset, location, and duration
was recorded. Prior to and following the intervention, we measured pain, disability, and TrA
and MF muscle thickness at rest and during contraction by visual analogue scale (VAS),
Functional Rating Index (FRI) questionnaire, and ultrasound imaging, respectively.
The VAS was used for pain assessment13). In this scale, pain was rated from 0 to 100mm, in
which the 0 represented no pain and 100 represented maximum pain tolerance. Subjects were
asked to mark the best number indicating their pain. The data were then recorded in the
Disability was evaluated through the Persian version of the FRI questionnaire. The
questionnaire served as a tool specifically designed for quantifying mental comprehension of
function and spinal pain in the clinical conditions. The reliability and validity of the
questionnaire have already been demonstrated in previous studies14). The questionnaire has 10
sections, and each section was rated using the same 5-point scale. Patients scored their
existing disability by choosing one of the grades (the grades ranged from 0 to 4, grade 0
meant without pain and able to complete the respective function, and grade 4 meant the
maximum pain and inability to perform the functions). The overall score was calculated by
the sum of the scores of all sections and was expressed by a percentage between 0 (no
disability) and 100 (severe disability).
Ultrasound imaging is a reliable and reproducible method for evaluation of muscle structure,
function, and activity15). This method allows assessment of muscle activity by measuring
changes in muscle geometry during contraction16). In this study, there was high intra-tester
reliability for the ultrasound measurements of the MF and TrA muscle thicknesses at rest and
during contraction (ICCs= 0.87 to 0.96). To measure the thicknesses of the MF and TrA
muscles, a B-mode ultrasound apparatus (MyLab 50 XVision, ESAOTE S.p.A, Genova Italy)
was used. Measurement of the thicknesses of the TrA and MF muscles was performed in a
resting position and during the tasks with submaximal muscle contraction on both sides17). To
record the thicknesses of the TrA and MF muscles, we used an LA523 linear probe (set to 12
MHz) and a CA431 convex array probe (set to 7.5MHz). In order to measure TrA muscle
thickness, the subjects were set in crook-lying position18). The ultrasound probe was placed
midway between the iliac crest and costal margin, on the midaxillary line, about 10cm off
the midline of body at the level of umbilicus19). TrA muscle thickness was measured in
millimeters between the fascial lines, one centimeter away from the muscle junction in the
direction of the thoracolumbar fascia18). The two submaximal tasks were performed for the
TrA muscle, the abdominal draw-in maneuver (ADIM) and active straight leg raising
(ASLR)20). MF muscle thickness measurements were performed in the prone position with a
pillow under the abdomen. The probe was placed along the spine, such that the midpoint of
the probe was in line with the spinous process of the fourth lumbar vertebra. Then it was
moved so that the facet joint between the fourth and fifth lumbar vertebrae was visible. This
point is located directly on the MF muscle. The muscle thickness was measured from this
point to the plane between the subcutaneous tissue and muscle16). The submaximal task for
this muscle was elevation of the contralateral arm in a prone position with a small weight

(0.5kg) on the arm, the elbow at a right angle, and the glenohumeral joint at 120 degrees of
For warming up and before performing specific exercises, participants pedaled a stationary
bike for 5 minutes and then did stretching exercises for 10 minutes13). Stabilization exercises
were divided into 6 levels from easy to difficult. At the end of each training level, participants
performed each exercise ten times for ten seconds with low intensity5, 13). During the
treatment session, between 80 and 100 repetitions of the selected exercises were carried out
in the McKenzie group22).
The stabilization exercises were performed in 6 steps: 1) Segmental Control Exercises (SCE)
with emphasis on training the of isolated contraction of the TrA, MF, and pelvic floor
muscles; 2) SCE with emphasis on co-contractions of the TrA, MF, and pelvic floor muscles
in the prone, supine, and four-point kneeling positions; 3) closed kinematic chain SCE; 4)
development of SCE into the low load apply by adding leverage of the limbs during open
chain exercises; 5) development of SCE in functional situations; and 6) co-contraction of
theTrA and MF muscles during application of an external load, complication of movements,
increased load with the lumbar spine in the correct position, addition of a co-contraction
pattern to light aerobic activities such as walking, and activities that have already
exacerebated the symptoms4).
In the Mckenzie group, 6 exercises were used: four extension-type exercises and two flexiontype and two flexion-type exercises. The extension-type exercises were performed in prone
and standing positions, and the flexion-type exercises were performed in the supine and
sitting positions. The final position of each exercise was maintained for 10 seconds23).
The data were collected over 10 months and were analyzed using SPSS version 17. They
were tested for a normal distribution using the Kolmogorov-Smirnov test. The independent
samples t-test was used for comparing the Mckenzie and stabilization groups. The paired-t
test was used to compare variables before and after training in each group. Statistical
significance for all tests was accepted below the 0.05 level.
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Demographic variables had a normal distribution. No significant difference was observed
between the demographic characteristics of the two groups. The patients demographic
characteristics are listed in Table 1. The study design and the corresponding flow diagram are
shown in Fig. 1. The following data were not distributed normally after treatment: resting
thickness of the left TrA, thickness of the left TrA during ADIM in the stabilization group,
and resting thickness of the right TrA in the McKenzie group.

Table 1.

Between-group baseline comparison of subjects characteristics

Fig. 1.
Flow diagram outlining progress throughout the trial
Pain decreased in both the Mckenzie and stabilization groups after the intervention (p <0.05).
The disability score decreased only in the stabilization group (p <0.05). The mean thickness
of the left MF muscle when contracted, resting thickness of the left TrA muscle, thickness of
the right TrA muscle during ADIM, and thickness of the left TrA during ASLR increased in
the stabilization group (p <0.05) (Table 2).

Table 2.
Means and standard deviations of variables within and between group comparison
Comparison of pain, function, and thickness of the TrA and MF muscles before treatment
showed no difference between two groups (p>0.05). The changs in the pain and disability
scores and right TrA muscle thickness during ADIM and the thickness of the left TrA muscle
during ASLR were greater than those in the stabilization group (p <0.05). Other variables
showed no significant difference between the two groups (p> 0.05) (Table 2).
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The results of this study showed that pain decreased following application of stabilization and
Mckenzie exercises. Disability decreased only after the application of stabilization exercises.
The results indicated that the effect of stabilization exercises on pain and disability was
greater than Mckenzie exercises in CLBP. Also, stabilization exercises were effective in
increasing the resting thickness of the left TrA muscle, the thickness of the right TrA muscle
during ADIM, the thickness of the left TrA muscle during active SLR, thickness of the left
MF muscle when contracted. Comparison of the effects between the two methods of
exercises on muscle thickness showed that stabilization exercises were more effective than
Mckenzie exercises in increasing the thickness of the right TrA muscle during ADIM, and the
thickness of left TrA muscle during ASLR.
Despite the borderline changes that occurred in the thickness of the TrA muscle when
contracted in Vasseljen and Fladmarks study9), in the present study, the thicknesses of the
TrA and MF muscles when contracted increased in some of the outcomes. In our study, the

exercise types were different from those used in Vasseljen and Fladmarks study. The results
of this study regarding the changes in resting thickness of the TrA muscles following
application of stabilization exercises were consistent with the study by Akbari et al8). They
showed an increase in resting thickness of the TrA and MF muscles following the application
of stabilization exercises8). In the present study, the resting thickness of the left TrA increased.
Accordingly, depending on the purpose of exercise applications, effects of exercises on the
muscles can lead to hypertrophy or neuromuscular adaptation9). With the emphasis placed on
low-level contraction and isolation of the TrA muscles during stabilization exercises, it is
expected that most of the effects of stabilization exercises are related to neuromuscular
adaptation9). However, muscle hypertrophy typically occurs after 8 to 12 weeks of intensive
strengthening exercises2, 24). Thus, we proposed that the short duration of the present study
and effects of neuromuscular adaptation led to changes in some of the outcomes.
The findings of this study are consistent with the findings of previous studies in terms of
improvement in pain and function following the application of stabilization exercises4, 6, 8, 13,
. Also, stabilization exercises were found to be superior to McKenzie exercises in
our study, as shown by the decreases in pain and disability, which is consistent with the
results of other studies7, 29). Although stabilization exercises are the most important methods in
rehabilitation of LBP disorders and in prophylaxis, the exact biological basis for the efficacy
of stabilization exercises in LBP patients is not clear yet30). Several mechanisms have been
proposed to describe the effects of stabilization exercises on pain26). These mechanisms
include reduction of load and improvement in the quality of movements following
improvement in co-ordination of trunk muscles31). In addition, the stabilization exercises
targeted the main deep muscle affected by LBP29, 32). As a result, deep muscle stabilizer
muscles could influence by stabilization exercises in LBP patients32). Therefore, a change in
muscle thickness was only seen after stabilization exercises.
Considering the above mentioned points, pain reduction in the Mckenzie group might have
occurred due to other causes without changes in the thickness of abdominal and MF muscles.
This approach was focused on sustained postures or repeated movements, and pain reduction
migth have been due to postural correction11).
Therefore, both types of exercises reduced pain in patients with nonspecific CLBP. Disability
was reduced only in stabilization group. Also, stabilization exercises were effective in
increasing the resting thickness of theleft TrA muscle, thickness of the right TrA muscle
during ADIM, thickness of the left TrA muscle during ASLR, and thickness of the left MF
muscle when contracted. Stabilization exercises were more effective than Mckenzie exercises
in reducing pain and disability, increasing the right TrA muscle thickness during ADIM, and
increasing the left TrA muscle thickness during ASLR.
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The study was funded and supported by Tehran University of Medical Sciences (Grant No:
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pp 1314.

Subdeltoideus Bursitis Manifested as

Gigantic Cystic Supraclavicular and
Lateralcervical Tumour
A. Demetrian,1 R. Melinte,2 I. Mndril,1 and Rodica Dilof1
Author information Article notes Copyright and License information
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The authors present a case of a left gigantic supraclavicular and lateralcervical tumor with
rapid growth, which has turned out to be a subdeltoideus bursitis.
Keywords: subdeltoideus bursitis, cystic tumour, supraclavicular, synovial liquid
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Case Report
We present the case of a 79 years old patient, who was admitted to the hospital for the
emergence within a relatively short interval (approximately two weeks) of a right
supraclavicular pseudotumoral formation of large dimensions (12/10 cm), in the absence of
any notion of trauma, intense effort, insect bite, surgical intervention or local diagnosing
procedure (puncture).
The formation presents characters of liquid fluctuation, without signs of local inflammation,
discretely painful at feeling and with minimum signs of compression at the level of the
brachial plexus (pain and moderate parestesis at the level of the upper right limb).
The movements in the right scapularhumeral joint, although possible and painless, proved to
be limited by the volume of the formation.
The thorax examination highlighted a minimum diminishing of the vesicular murmur in the
upper third of the right hemithorax, without clinical signs of pleuresis of the large right
During the commitment period, the formations increase in volume continued, with a right
lateralcervical evolution, maintaining the fluctuant character at feeling.
The cervical-thoracic computer-tomographic examination indicated the presence of a
formation with cystic aspect, oval-like, well bordered, of 7.6/6.4 cm, situated supraclavicular
right, located medial of the trapezius muscle, lateral of the scapula lifting muscle and the
medial and posterior scalene muscles; the carotid artery and the jugular vein without visible
modifications (fig. (fig.11).

Computer-tomograph images of the case
The imagistic data and the clinical aspect suggested the existence of a subdeltoideus bursitis.
We performed the formation draining puncture through a posterior percutaneus aboard, with
the draining of 400 ml serous citrin liquid and the subsequent total disappearance of the
regional deformation.
The cytologic examination of the liquid extracted indicated an inflammatory aspect with rare
cellular elements (lymphocytes, polymorphonuclear leucocytes, cropped out nuclei, red blood
corpuscles and cellular detritus).
The evolution was favorable, with the total disappearance of the cystic formation and of the
minimum symptomatology described previously.
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The shoulder is not constituted solely of the glenohumeral joint, but from several joints that
make up the shoulders articular system. The number of joints is different, the authors
including in this articular complex 7 (Cailliet R., 1984), 5 (Kapandji I. A., 1966) or 3 (Bonnel
F., 1988) joints [1].
The variety of the complex movements performed in these joints is possible also due to the
existence of the periarticular muscles and of the perihumeral synovial bursae.
The vast space occupied by the synovial cavities within the shoulders articular system raises
the issue of the role of the synovia in the biomechanics of this system, the synovia behaving
as a intermuscular liquid cushion with role in modulating the movements of the shoulder and
arm [2].
By means of a minute dissection in the deltopectoral space, with the clavicular desinsertion of
the deltoid muscle and the removal towards the side of the obtained flap, it is possible to
visualize the prominences of the upper humerus extremity: the small tuberculum and the large
tuberculum, separated by a depression well visible due to the transparency of the conjunctive
In the intertubercular space there is identified the tendon of the long biceps portion, with its
synovial bursa homologated as "vagina synovialis intertubercularis". It is a synovial covering
considered as an extension of the sinovia of the glenohumeral joint which accompanies the
bicipital tendon for 4-5 cm in the intertubercular channel.

Lateral and superior of the prominence determined by the large tuberculum of the humerus, it
is located the synovial subdeltoideus bursa, which presents as a sliding space between the
acromiocoracoid arch and the deltoid muscle. After the opening of this bursa, the space under
the acromiocoracoid arch can be easily explored [3].
In a profound foreground there is the conjunctive acromiocoracoid arch underneath which it
is possible to enter the subacromial bursa interposed between the acromial arch and the
acromiocoracoidian ligament. After the sectioning of this ligament in a sagittal plan, one can
visualize the posterior extension of the subacromiocoracoid space.
The scapularthoracic joint, also described by Gill and named by Latarjet "scapularthoracic
junction" [4], is a physiological joint which has two sliding spaces: the omodentatus space
and the parietodentatus space. These spaces are occupied by sinovial bursae: a superficial
bursa, inconstant, present between the inferior angle of the scapula and the latissimus dorsi
muscle; the scapulartrapezoidal bursa, between the superior angle of the scapula and the
trapezius muscle; two deep bursae, the scapularthoracic bursa bordered by the anterior
dentatus muscle and the thoracic wall and the subscapular bursa between the anterior dentatus
and the subscapular muscles [5].
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The scapularthoracic bursitis can cause important pain and the limiting of movements in the
scapular-humeral joint. The diagnosis is often one of exclusion, many times being made after
a long period in which the symptoms persist or aggravate [6].
In our case, this interval was relatively short due to the impressive volume and the rapid
growth pace which determined the patient to come to the physician.
The affection can be idiopathic (the case presented) or due to an abnormal mechanics
between the scapula and the secondary ribs grid, to a bone focal lesion (elastofibroma,
osteocondroma) or to the altered morphology of the thoracic wall posttraumatic or
postsurgery [7].
Sometimes, the existence of a bursitis can cause crepitations during movements.
The diagnostic arsenal comprises the ecohgraphy, the computer-tomography and the nuclear
magnetic resonance.
The medical treatment consists of non steroid anti-inflammatories and cyclooxygenase
inhibitors. Sometimes, the local application of ice or heat can be benefic. Some
rheumatologists practice locale injections with corticoids inside the bursa.
In our patient, we considered the liquid draining procedure more adequate than the treatment
described above for two reasons: the total absence of the pain syndrome and the impressive
dimension of the formation.

In case of relapse (important re-accumulation of liquid), we would have been forced to resort
to the arthroscopic removal of the bursa walls.
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1. Bonnel F., Blotman F., Mansat M., editors. L`epaule . L`epaule degenerative, l`epaule
traumatique, l`epaule du sportif. Diagnostique Reeducation Chirurgie Arthroscopie.
Paris; Berlin : Springer; 1993. pp. 365.
2. Melinte Rodica, Dragoi G.S., Melinte P. Razvan, Dogaru C. Raluca. A new Concept for
describing the movements in the glenohumeral joint. Acta of Bioengineering and
Biomechanics; The 13th European Conference of Biomechanics; 2002 September 2-4 ;
Wroclaw, Poland. 2002. pp. 626627. The 13th European Conference of Biomechanics,
September 2-4, 2002, Wroclaw, Poland.
3. Drgoi S.G., Rodica Melinte, Mndril I., Mihaela Niculescu, Melinte V. R. Contribuii la
studiul evaluarii handicapului i prejudiciilor aduse structurilor sistemului articular al
umrului. Implicaii n expertiza clinic medico-legal Revista Romn de Medicin Legal
4. Testut L., Latarjet A. Traite d'Anatomie humaine. 8. 1928. 1928. huithieme edition, revue
corrigee et augmentee par Latarjet.
5. Williams G.R., Shakil M., Klimkiewicz J., Iannotti J.P. Anatomy of the scapulothoracic
articulation. Clin Orthop Relat Res. 1999 Feb;359:237246. [PubMed]
6. Saboeiro G. R., Carolyn M. Sofka. Imaging-Guided Treatment of Scapulothoracic Bursitis.
HSS J. 2007 Sep;3(2):215undefined. [PMC free article] [PubMed]
7. Fujikawa A, Oshika Y, Tamura T, Naoi Y. Chronic scapulothoracic bursitis associated with
thoracoplasty. AJR Am J Roentgenol. 2004;183(5):1488undefined. [PubMed]