Background
Postural abnormality is one of the main symptoms of Parkinson’s disease (PD). This most commonly takes the form of trunk anteflexion, but scoliosis is also seen. The erector spinae muscles are essential to trunk movement and the maintenance of an upright posture, and weakness of these muscles exacerbates postural abnormality [
1]. The erector spinae are controlled by the corticospinal and reticulospinal tracts [
2]. Because patients with PD develop extrapyramidal symptoms, these may affect the erector spinae at an early stage soon after onset.
A previous magnetic resonance imaging (MRI) study of the paraspinal muscle mass of patients with PD reported that they were asymmetrical, with greater muscle atrophy on the side on which the PD symptoms first became evident than on the opposite side in eight of 10 patients [
3]. In another study, the proportion of type 1 fibers in lateral vastus muscle biopsies from patients with PD was higher than those from either young or older healthy individuals [
4]. Skeletal muscle fatigability also contributes to PD symptoms, and a number of studies have suggested that mitochondrial dysfunction may be involved [
5,
6]. Thus, there is no association between the proportion of muscle fiber types and mitochondrial function in patients with PD. To our knowledge, no study has yet addressed the fatigability of the erector spinae in patients with PD. Evaluating the fatigability of the erector spinae in patients with PD might contribute to the development of effective interventions for preventing the progression of postural abnormality or even improving it, and is therefore of clinical value.
One method of evaluating the fatigability of the erector spinae is to use electromyography (EMG) to measure muscle activity during the Sørensen back endurance test [
7,
8], in which the subject’s lower extremities are fixed to a bed and they maintain their trunk in the horizontal position without support. The median frequency (MF) calculated by frequency power spectrum analysis of the recorded surface muscle activity attenuates over time. Because the degree of MF attenuation is highly reliable [
9] and is associated with the proportions of muscle fiber types [
10], it is widely used as an indicator of erector spinae fatigability by clinicians and researchers [
11‐
15].
In a systematic literature review aimed at examining the validity and applicability of methods for the assessment of erector spinae muscle fatigability in everyday clinical rehabilitation practice, the Sørensen back endurance test combined with surface electromyography spectral analysis has been shown to be the most widely used and the comparatively most optimal modality currently available to assess objective erector spinae muscle fatigability. However, patients who have severe erector spinae muscle weakness might not be able to maintain the pose for even just a few seconds [
16]. Therefore, whether patients with PD with abnormal posture are capable of performing the Sørensen back endurance test is unknown.
Against this backdrop, we hypothesized that maximum muscle strength is severely diminished and fatigability of the erector spinae is high from an early stage in patients with PD. The objectives of this pilot study were (1) to verify whether the Sørensen back endurance test can be used to evaluate muscle fatigability of the erector spinae in patients with PD, and (2) to measure the fatigability of the erector spinae on the side on which PD symptoms first appeared and the opposite side in patients with PD, to compare the results with data on the erector spinae of healthy volunteers.
Discussion
The main finding of this study is that only 53% of patients in the PD group were able to perform the Sørensen back endurance test, a significantly lower proportion than in the control group, which consisted of healthy individuals matched for age, sex, and physical characteristics (100%). The trunk extension MVC values of those patients in the PD group who were able to perform the Sørensen back endurance test were also significantly lower than those of the control group participants, and their Sørensen back endurance test holding times were significantly shorter. In addition, although there was no difference in the MF slope of the erector spinae between the side on which symptoms originally appeared and the opposite side in patients with PD, it was significantly attenuated in both compared with the erector spinae of healthy individuals.
Around half of the patients with PD in this study were unable to perform the Sørensen back endurance test. According to previous reports, the Sørensen back endurance test requires approximately 40% MVC [
23]. The fact that around half of the patients with PD in this study were unable to perform the Sørensen back endurance test and that the mean MVC of those patients with PD who were able to perform it was equivalent to 50% of the mean MVC of the control group suggests that the majority of modified H-Y Stage < 3 patients with PD have a trunk extension muscle strength of less than 50% of that of healthy individuals of the same age. Some reviews [
16,
24] have previously reported that the relative intensity of the Sørensen back endurance test varies by virtue of differences in age, body mass index, and muscle strength. In the current study, the PD group and the control group were matched for age, sex, and physical characteristics, but the possibility that the relative strength needed for the Sørensen back endurance test is higher because the extensor muscle strength of patients with PD is severely reduced must be kept in mind when interpreting the MF slope.
According to a previous study that combined histopathological testing and frequency power spectrum analysis [
25], MF attenuation is more gradual when there is a higher proportion of type 1 muscle fibers, which have better endurance, and steeper when there is a higher proportion of type 2B muscle fibers, which lack endurance; the MF slope therefore provides an index of the fatigability of skeletal muscles. The erector spinae are postural muscles that contain predominantly type 1 muscle fibers [
26], and the MF slope calculated from erector spinae activity during the Sørensen back endurance test is reportedly correlated with the proportion of type 1 fibers [
10]. In the current study, the MF values calculated for the erector spinae of patients with PD exhibited similar attenuation on both sides, but this attenuation was steeper than that seen in the control group. That is, compared with the control group, the fatigability of the erector spinae in patients with PD was greater, suggesting that they may have contained a lower proportion of type 1 fibers than normal. However, previous studies have reported that the skeletal muscles of patients with PD exhibit fatigability despite their high type 1 fiber content [
4], and it has been suggested that this may be due to mitochondrial dysfunction [
5,
6]. We therefore conjecture that even if the proportion of type 1 fibers was high, a lack of mitochondrial activity may have reduced the efficiency of the aerobic metabolism, and the MF slope thus reflected the resulting quality of the erector spinae.
This study has a number of limitations. The first is the small sample size. However, because the patients with PD included in this study were all older women with a modified H-Y Stage < 3, and since we compared their results with those of healthy individuals matched for age, sex, and physical characteristics, we consider the clinical significance of our data high. The second limitation of the current study is that in our investigation of differences in MF slope between the PD and the control group, the severe reduction in erector spinae muscle strength in the patients with PD may have increased the relative load during the Sørensen back endurance test for the PD group. As this was a cross-sectional study, however, it is impossible to determine whether the difference in MF slope between the two groups was due to changes in the muscle fiber composition of the erector spinae or to differences in the relative intensity of the Sørensen back endurance test. In either case, however, this is the first study to demonstrate that the fatigability of the erector spinae, which contributes greatly to postural maintenance, is greater in patients with PD.
We found that only 53% of modified H-Y Stage < 3 patients with PD were able to perform the Sorensen back endurance test, and that trunk extensor muscle strength was greatly reduced and the fatigability of the erector spinae was higher in the PD group. However, there is no universal agreement with regard to the appropriate assessment of erector spinae muscle fatigability with the Sørensen back endurance test. Test subjects exhibited significantly longer holding times during the modified Sørensen back endurance test on a 45-degree Roman chair than on the original Sørensen back endurance test. Moreover, moderate and significant correlation between both tests was observed for holding time, and there was no difference in MF slope derived from erector spinae between both tests [
27]. Therefore, the modified Sørensen back endurance test on a Roman chair might be a good choice to assess erector spinae muscle fatigability in patients with PD. However, erector spinae muscle fatigability data from the modified Sørensen back endurance test on a Roman chair is scant and the validity and reliability of the test therefore need to be more fully evaluated. In addition, previous studies reported that PD patients with postural abnormalities such as camptocormia, Pisa syndrome, and anterocollis have greater disability, higher risk of falls, and worse quality of life [
28]. It is thus important to evaluate the correlation between erector spinae muscle fatigability and spine alignment, muscle volume, disability, fall tendency, and quality of life for patients with PD.
Our findings suggest that there is a marked decline in the quality of the erector spinae on both sides from the initial stage of PD, and that symmetrical strengthening of the endurance of the bilateral erector spinae from the early stage of the disease is required. An effective method of muscle strength training for the erector spinae in patients with PD has yet to be established. The trunk extension MVC of patients with PD is severely reduced, and we conjecture that high-intensity training may be clinically problematic in many cases. With respect to setting the intensity of muscle strengthening training, it has recently been suggested that low-intensity training to the point of exhaustion may activate both type 1 and type 2 fibers, leading to the same degree of muscle enlargement as high-intensity training [
29]. As soon as they are diagnosed, patients with PD must therefore engage in bilaterally symmetrical muscle strengthening training of the erector spinae at a load that enables them to continue for as long as possible, under the medical management of a rehabilitation therapist or similar professional. Trunk extension exercises on a Roman chair would allow patients to train the erector spinae muscles more specifically by overloading them over a longer duration [
30]. Aerobic exercise in a format that activates the muscle activity of the paraspinal muscles increases the aerobic metabolism, which contributes to increasing the size of type 1 muscle fibers [
31] and may prevent the progression of postural abnormality. Regular rowing exercise has also been suggested to strengthen the erector spinae [
32].
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