Modic Changes & Their Associations With Clinical Findings Per Kjaer Associate professer Department of Sports Science and Clinical Biomechanics, University of Southern Denmark
The Clinical Questions What are the mechanisms underlying the patient s pain? Could Modic Changes be the cause? Are there particular characteristics in a patient s history and physical examination findings?
Overview Definition of Modic changes Ætiology Definition of clinical findings Characteristics from history taking physical examination Conclusion
Type 1 Modic type 1 MRI Low T1-signal High T2-signal Histology Fibro-vascular tissue Fissured endplates Modic et al 1988 Blum et al 2009 Albert et al 2009 T1 T2
Type 2 Modic type 2 MRI High T1-signal High T2-signal Histology Fatty bone marrow Fissured endplates Modic et al 1988 T1 T2
Type 3 Modic type 3 MRI Low T1-signal Low T2-signal Histology Sclerosis Disc calcification Modic et al 1988 Karamouzian et al 2010 T1 T2
Suggested Causes Genetic Autoimmune Biomechanical Infectious Karppinen et al 2008 and 2009 Ma et al 2011 Rahme et al 2008 Albert et al 2008, 2009 and 2013 Hu et al 2009 Wedderkopp 2009
Biomechanical theory Normal disc Degenerated disc
Biomechanical theory Degenerated disc Degenerated disc
Infection theory Normal disc Disc disruption
Clinical Findings Information from patient s history Patient s interview Questionnaire Information from physical examination Movement Palpation Provocation test Pain threshold
No Disc degeneration or Modic Disc degeneration (DD) Modic changes & Disc degeneration
Study population and variables Backs on Funen Denmark 412 people from general population aged 40 MRI Disc degeneration (DD): reduced signal or height Modic changes (MC): one or more signal changes Questionnaire LBP history Work and lifestyle Functioning Physical examination
The 3 groups Neither MC nor DD 179 DD 141 MC & DD 73
Percentage Patient history Reporting LBP 100 90 80 70 60 50 40 30 MC & DD DD only Neither 20 10 0 Past week Past month Past year Seeking care Non-trivial LBP P<0.003
Percentage LBP history 100 90 80 70 60 50 40 MC & DD DD only 30 20 10 0 Any previous episodes LBP Previous disc herniation Neither p<0.01
Percentage Work and lifestyle 60 50 40 MC & DD 30 20 DD only Neither 10 0 Heavy phys work Vibrations Body mass index High level leisure Heavy smokers
Percentage Different definitions of functioning 35 30 25 MC & DD 20 15 10 DD only Neither 5 0 Downtime work Downtime leisure Sick leave Reduced sports Physical function p<0.01
Percentage Physical examination 60 50 40 30 20 10 0 Flat back Pain on Lumbar movement PPT NMK Activation of LMM Lumbar pain tolerance p<0.03
And after that 54 citations in Web of Science, 463 hits in PubMed One conference proceeding and a paper Have reduced ROM in Flexion (clbp) One paper Bendix et al 2006 Hard work combined with overweight and smoking increased the probability of Modic Changes but not LBP One bachelor s thesis Lebouf-Yde et al 2008 Pain on return from lumbar flexion increased probability of Modic Changes Tang and Skrostrup 2008
And after that, cont 36 patients with chronic LBP in three subgroups Rannou et al 2007 The Modic subgroups had: and and higher serum hscrp level (Type 1) Longest duration of pain, longer period with morning stiffness, worst painful moments late night/morning, more pain during Valsalva maneuver Exacerbation of pain on hyperextension
Other factors Increasing the probability of having modic changes BMI Age Previous disc herniation Arena et al 2011, Kuisma et al 2008 Wang et al 2012, Albert et al 2008 Albert et al 2007
The Clinical Question What are the mechanisms behind the patients pain? Could Modic Changes be the cause? Are there particular characteristics in a patient s history and physical examination findings associated with Modic Changes? (Does the presence of Modic Changes have any consequence for the management of this patients pain?)
The answer As a group, the people with Modic Changes seem to be worse in terms of pain, disability and participation physical impairments Reduced and painful movements Positive pain provocation test Particular risk factors previous lumbar disc herniation Overweight, hard work and smoking On an individual level, we cannot know
Conclusion We can only cautiously suggest to an individual patient that he or she may have an increased probability of Modic Changes But 25 June 2009
Thank you for listening 26 June 2009
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