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Peer-reviewed

Research Article

Age-Related Loss of Lumbar Spinal Lordosis and Mobility – A Report of 323 Asymptomatic Volunteers

• Marcel Dreischarf,
• Laia Albiol,
• Antonius Rohlmann,
• Esther Pries,
• Saying Bashkuev,
• Thomas Zander,
• Georg Duda,
• Claudia Druschel,
• Patrick Strube,
• Michael Putzier

10

• Published: December 30, 2014
• https://doi.org/10.1371/periodical.pone.0116186

Figures

Abstract

Background

The understanding of the private shape and mobility of the lumbar spine are central factors for the prevention and handling of low dorsum pain. The influence of historic period and sexual activity on the total lumbar lordosis and the range of motion equally well equally on different lumbar sub-regions (lower, middle and upper lordosis) in asymptomatic subjects still merits word, since it is essential for patient-specific treatment and evidence-based distinction between painful degenerative pathologies and asymptomatic aging.

Methods and Findings

A novel non-invasive measuring system was used to assess the total and local lumbar shape and its mobility of 323 asymptomatic volunteers (age: 20–75 yrs; BMI <26.0 kg/m^two; males/females: 139/184). The lumbar lordosis for standing and the range of motility for maximal upper trunk flexion (RoF) and extension (RoE) were determined. The total lordosis was significantly reduced by approximately 20%, the RoF by 12% and the RoE by 31% in the oldest (>l yrs) compared to the youngest age cohort (twenty–29 yrs). Locally, these decreases by and large occurred in the middle part of the lordosis and less towards the lumbo-sacral and thoraco-lumbar transitions. The sex simply afflicted the RoE.

Conclusions

During aging, the lower lumbar spine retains its lordosis and mobility, whereas the centre function flattens and becomes less mobile. These findings lay the ground for a amend understanding of the incidence of level- and historic period-dependent spinal disorders, and may accept important implications for the clinical long-term success of unlike surgical interventions.

Citation: Dreischarf Thou, Albiol L, Rohlmann A, Pries Eastward, Bashkuev M, Zander T, et al. (2014) Age-Related Loss of Lumbar Spinal Lordosis and Mobility – A Study of 323 Asymptomatic Volunteers. PLoS ONE 9(12): e116186. https://doi.org/10.1371/periodical.pone.0116186

Editor: Xing-Ming Shi, Georgia Regents University, The states

Received: August 13, 2014; Accepted: December three, 2014; Published: December 30, 2014

Copyright: © 2014 Dreischarf et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted utilize, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the paper.

Funding: This report was supported financially by the Deutsche Forschungsgemeinschaft (DFG PU 510/2-one), Bonn, Deutschland, and by the Bundesinstitut für Sportwissenschaft, Bonn, Germany (MiSpEx – Network). The funders had no part in report pattern, data collection and analysis, determination to publish, or preparation of the manuscript.

Competing interests: Except of Antonius Rohlmann and Esther Pries, all authors of this manuscript accept no conflict of involvement. None of them have whatever relationships to products or companies mentioned in or related to the field of study matter of the commodity beingness submitted. None of the authors have any pertinent fiscal relationships, such as consultancies, stock ownership or other disinterestedness interests or patent-licensing arrangements for any product or process mentioned in the submission. Simply Antonius Rohlmann was a consultant of the Epionics Medical GmbH and Esther Pries is a scientific adviser of the Epionics Medical GmbH. Withal, this does not influence the results of the nowadays study and does not alter the authors' adherence to PLOS ONE policies on sharing information and materials.

Introduction

The individual shape of the lumbar spine is an essential predictor for dissimilar lumbar degenerative pathologies and for the success of various surgical interventions [ane]–[5]. Moreover, the mobility of the lumbar spine is discussed every bit an indicator for abnormal spinal mechanics [6], [vii]. The influence of the factors age and sex on the full lumbar lordosis and the range of motion (RoM) still merits discussion, because it is essential for a patient-specific treatment, for instance, with regard to patient age and disease localisation, and evidence-based distinction between painful degenerative pathologies and asymptomatic aging. Despite their influence, the impact of these factors on certain regions of the lumbar spine and its mobility, including upper, center and lower lumbar spine, remains unknown.

Most studies on the consequence of age showed that lumbar lordosis decreases or remains constant during the lifetime [8]–[21]. Only a few studies demonstrated an increment in lumbar lordosis with crumbling [22], [23]. Studies investigating sex-related differences in lordosis showed either a slightly greater lordosis in females or no significant dependency on sex [24]–[27]. However, several of these studies investigating age and sexual activity were express in their sample sizes, did not differentiate between males and females and subjects with or without low back hurting. Moreover, in almost all of these studies the whole lumbar lordosis was usually described by a single angle (e.one thousand. Cobb'due south method), which strongly simplifies the complex lumbar curvature [28]–[30]. A more than detailed assay, including of different lumbar sub-regions, may reveal that the upper, middle or lower lumbar lordosis are affected specifically, for example, by aging.

In addition to the individual shape of the lumbar lordosis, it is generally accustomed that the total RoM in flexion-extension is reduced with increasing historic period [6], [31]–[39]. However, similar to lumbar lordosis, it remains unknown, which lumbar sub-region is affected dominantly by aging in males and females. Knowledge nigh local changes in spinal function with aging may therefore help to optimise and suit the handling to the diseased spinal level.

Because detailed segmental diagnostic Ten-ray examinations are ethically questionable in healthy individuals and very laborious in large cohorts, a new technological approach was kickoff identified and further developed by our grouping [40], which would permit assay of the total and local lordosis also every bit the spinal function (east.one thousand. by means of RoM). Using this sophisticated, strain-approximate based tool that had been validated previously, the present written report investigated the effect of age and sex on the lordosis and on the RoM for the whole lordosis also as for the unlike lumbar sub-regions in asymptomatic volunteers across the developed lifespan. It was hypothesised that:

1. crumbling reduces the total lumbar lordosis and the full range of motion in flexion (RoF) and extension (RoE) of the lumbar spine,
2. locally, the change in lordosis and mobility with aging varies between unlike lumbar sub-regions,
3. the full lumbar lordosis is larger in females than in males.

Materials and Methods

Measuring arrangement

The lumbar and thoraco-lumbar shape and the mobility of the spine in the sagittal plane were dynamically determined with the Epionics SPINE system (Epionics Medical GmbH, Potsdam, Germany). The arrangement has the advantage over X-ray techniques that the volunteers are not exposed to radiation and thus several repeated measurements are possible. Furthermore, unlike sub-regions of the lumbar lordosis, including the lower, middle and upper lordosis, tin be analysed. The high accuracy and reliability of the system was reported previously [twoscore], [41].

The arrangement consists of two flexible sensor strips, which are placed in hollow plasters onto the volunteers' dorsum (Fig. 1). Each of the strips are positioned paravertebrally approximately seven.five cm from the mid-sagittal plane while the everyman part of the strips is positioned at the level of the posterior superior iliac spine (approximately first sacral vertebra). Each sensor strip consists of twelve 25-mm-long single sensor units (Epionics segments: S1–S12) containing strain-gauge technology. Each sensor unit detects the local back curvature as illustrated in Fig. 1. The data from all 12 sensors is collected at 50 Hz and saved locally on a modest storage unit of measurement (12.5 cm×5.5 cm; mass: 120 m) carried on a chugalug, assuasive free unhampered movements of the volunteer. An accelerometer is located at the lower finish of each sensor strip to assess the orientation of the sensors in relation to earth'south gravitational field. A detailed clarification of the organization has been published elsewhere [40], [41].

Figure one. Epionics SPINE organisation with the positions of the Epionics segments S1–S12.

On average, the lumbar lordosis is covered by the first six segments (shown in cherry). Heart: Schematic sketch of the definition of the determined segmental bending is shown for a single exemplary sensor unit of measurement S2.

https://doi.org/10.1371/journal.pone.0116186.g001

Volunteers

Measurements were performed on 429 asymptomatic volunteers (198 males, 231 females). Subjects were free from acute low back pain and had no depression back pain within the previous 6 months. Furthermore, volunteers had no previous spinal surgery.

Own validation and previously published studies showed that there is a significant correlation (Spearman'due south correlation: 0.86, p<0.01 [42]) between the total lumbar lordosis measured on the dorsum and the radiologically determined lordosis in subjects with a BMI <26.0 kg/mⁱⁱ. Moreover, this value of 26.0 kg/thou² is considered every bit the normal-weight limit for subjects with an age similar to the mean age of the hither investigated cohort (National Research Council, [43]) and was set to the BMI-limit in the present study.

The volunteers were classified for sexual activity and assigned to four historic period groups: 20–29 years, thirty–39 yrs, 40–49 yrs and>fifty yrs, every bit was done in previous studies (eastward.g.: [xv], [44]).

Measurement protocol

The volunteers performed standardised move choreographies in the sagittal plane. For guidance and standardisation, the volunteers watched a video prior to the do, which explained and demonstrated the exercise. Starting from a relaxed continuing position, the volunteers were asked to perform a maximal upper body flexion and extension with extended knees up to half-dozen times. Before each practise, the subjects were measured in a relaxed standing position. Each volunteer performed the movements at his or her own preferred speed.

Data analysis

All Epionics sensor segments (S1–S12, Fig. 1) and the total lumbar lordosis were evaluated for the three investigated body positions: standing, maximal flexion and maximal extension of the upper body. The results of the left and correct sensor strips were averaged. The total lumbar lordosis in continuing of each volunteer was determined individually as the sum of all lordotically curved segments. The full angles for flexion and extension were calculated individually as the sum of the segments, which were identified as existence lordotic during upright standing. The total RoF and RoE in the lumbar spine for each field of study were calculated as the maximal or minimal bending difference with respect to standing.

Statistical Assay

Descriptive statistics (hateful, standard mistake, standard deviation) were analysed using SPSS 21.0 (SPSS Inc., Chicago IL, U.s.). The Kolmogorov-Smirnov test was performed to evaluate the normal distribution for each investigated group. In improver, the Levene's test was performed to test equality of variance. A two-style analysis of variance (ANOVA) with the factors age and sex was performed to evaluate the effects on the total lumbar lordosis, total RoF and total RoE. Later on, the mean values of the lordosis, RoF and RoE of the Epionics segments of different age groups were compared sexual activity-specifically using a 1-way ANOVA followed by post-hoc analysis using Scheffé'southward test. A p-value <0.01 was considered as statistically significant.

Ideals Argument

This study was canonical by the Ethics Committee of the Charité – Universitätsmedizin Berlin (registry number EA4/011/10). The process of this study was explained to each volunteer in particular and they signed a written informed consent, which allows spinal shape determinations with the Epionics SPINE device.

Results

Volunteers

Due to the defined BMI-threshold of 26.0 kg/mⁱⁱ, 106 volunteers were excluded from the initial sample of 429, which resulted in a terminal number of 323 subjects (males: 139, females: 184). The hateful values for body peak, body weight and BMI for all the age cohorts are given in Tabular array one.

Total and local lumbar lordosis during continuing

The Kolmogorov-Smirnov test showed that the lumbar lordosis followed a normal distribution for both sexes. Two-way ANOVA demonstrated that the full lumbar lordosis was only significantly associated with age, only non with sex (Table 2). For the whole sample, this reduction of the full lordosis with age occurred with each sequent age group (Fig. two top; Table 3). There was a significant reduction of approximately 7.4° (≈xx%) betwixt the youngest and the oldest accomplice. This decrease was more evident in females, who showed a significant reduction of 7.9°, than in males with 6.7°, which was only shut to pregnant (p = 0.034). For both sexes, in that location was only a pocket-sized lordosis reduction between xx–29 yrs and xxx–39 yrs. In the following aging process, females showed a continuous decrease, while the reduction in males mostly occurred between the ages thirty–39 yrs and forty–49 yrs. The smallest total lordosis in males was measured inside the twoscore–49 yrs group. Post-hoc comparison demonstrated no statistical differences betwixt the 40–49 yrs and>l yrs age groups (p = 0.977) in males, whereas there was a significant reduction of the lordosis between the xx–29 yrs and the forty–49 yrs age groups (p = 0.009).

Effigy 2. Mean values of the full lumbar lordosis (top), total range of flexion (centre) and total range of extension (bottom) in all four investigated age groups for the whole accomplice (grey columns).

The scarlet lines represent males and the blue lines females. Fault confined stand for the standard deviation.

https://doi.org/10.1371/periodical.pone.0116186.g002

On boilerplate, the first 6 Epionics segments (S1–S6) were lordotic in the present cohort (Figs. 1, 3 A) and are therefore presented here. Epionics segments above those were part of the thoraco-lumbar transition and lower thoracic kyphosis. Locally for both sexes, the greatest loss of lordosis occurred in the middle office of the lordosis with a tendency towards the upper office. Mostly, less reduction was observed towards the thoraco-lumbar and lumbo-sacral transitions (Fig. 3B; Table three). The largest accented loss of lordosis between the youngest and oldest cohorts occurred in the Epionics segment S4 with values of two–3°. The lower segments S1 and S2 and the upper segment S6 showed no significant differences for the whole sample, nor for males and females separately. For the relative change, the lordosis of the youngest cohort was fix to 100% in Fig. iii C. In males, the largest relative reduction of the lordosis occured in S6 (to 54% of the reference) with continuously less reduction towards the most caudal segment S1 (to 101%). In females, the largest relative reduction occurred in S5 (to 69%), with continuously less reduction to the most caudal segment S1 (to fourscore%) and furthermore less in S6 (to 81%). These local changes in males and females led to a characteristic alter betwixt the 'young' and the 'old' lordosis as illustrated in Fig. iv.

Figure three.

Mean values of the segmental lordosis for the Epionics segments S1 to S6 in all investigated historic period groups (A). Males (above) and females (below) are shown separately. Mistake bars represent the standard difference. (B): Absolute alter in segmental lordosis for the Epionics segments S1 to S6 in all investigated age groups in relation to the youngest accomplice (20–29 yrs) for males (to a higher place) and females (below) separately. The youngest accomplice is normalised to 'zero' as a reference. The ruby-red surface area highlights the pattern of the absolute change between the oldest and youngest cohorts. (C): Relative change in segmental lordosis for the Epionics segments S1 to S6 between the oldest and youngest age groups for males (above) and females (below) separately. The youngest cohort is normalised to 100% as a reference. Values indicate the percentage of lordosis that the oldest cohort possesses in relation to the youngest cohort. The ruddy surface area highlights the design of the relative changes between the oldest and youngest cohorts.

https://doi.org/ten.1371/periodical.pone.0116186.g003

Full and local range of flexion and extension during standing

The Kolmogorov-Smirnov test showed that the RoF and RoE were normally distributed in male and female cohorts. The full RoF and RoE were significantly associated with age (Table 2). Moreover, the full RoE, merely not the total RoF, was significantly associated with sex.

For the whole sample as well as for males and females separately, the full RoF showed no pregnant difference betwixt the 20–29 yrs and 30–39 yrs age cohorts, but a consecutive decrease for the subsequent age groups (Fig. 2 middle; Table iv). Although meaning, the total RoF was reduced by only approximately 12% (half dozen.2°) when comparing the youngest and oldest cohorts of the whole sample. This subtract was only significant for males, with a loss of viii.6°. In females, the reduction was merely 4.2°.

Males and females showed like local patterns for the reduction of the RoF with increasing historic period. This local reduction was most dominantly in the middle part (S3, S4) of the lumbar region (Fig. v A, B; Table 4). In general, the Epionics segments close to the thoraco-lumbar and lumbo-sacral transition (S1, S6) showed not-significant absolute changes with increasing historic period. Males tended to display a slightly greater reduction relative to the youngest cohort than females, with the greatest loss in segment S5 (to 73% of the reference; Fig. 5 C). In females, the largest relative reduction occurred in S4 (to 80%).

Figure 5.

Mean values of the segmental range of flexion (RoF) for the Epionics segments S1 to S6 in all investigated age groups (A). Males (to a higher place) and females (below) are shown separately. Error bars represent the standard departure. (B): Absolute modify in the segmental RoF for the Epionics segments S1 to S6 in all investigated age groups in relation to the youngest cohort (20–29 yrs) for males (above) and females (below) separately. The youngest cohort is normalised to a value of 'zero' as a reference. The reddish surface area highlights the blueprint of the absolute alter between the oldest and youngest accomplice. (C): Relative change in the segmental RoF for the Epionics segments S1 to S6 between oldest and youngest age groups for males (in a higher place) and females (beneath) separately. The youngest cohort is normalised to 100% every bit a reference. Values indicate the percentage of the RoF the oldest cohort possesses in relation to the youngest accomplice. The red expanse highlights the pattern of the relative changes between the oldest and youngest cohorts.

https://doi.org/10.1371/journal.pone.0116186.g005

The full RoE of the whole sample was reduced for each sequent age cohort and was significantly decreased by approximately 31% when comparing the youngest and oldest cohort (Fig. two lesser; Table iv). The loss of the RoE was more pronounced and only significant in females (12.4°). Males showed a smaller reduction of only 5.8°. Independent of historic period, males had a smaller total RoE than females.

For the local RoE, males and females both showed the largest absolute reduction in the middle part of the lordosis (S3; Fig. 6 A, B) and, like to the local RoF, less reduction towards the transition zones. However, in females, the absolute and relative reductions were more pronounced in the heart and lower Epionics segments (Fig. 6 C). Males showed no significant and only small relative changes in the Epionics segment S1. In both sexes just minor non-significant changes in the RoE occurred in segments close to the thoraco-lumbar transition (S5, S6).

Figure 6.

Mean values of the segmental range of extension (RoE) for the Epionics segments S1 to S6 in all investigated age groups (A). Males (above) and females (below) are shown separately. Fault confined stand for the standard deviation. (B): Absolute alter in the segmental RoE for the Epionics segments S1 to S6 in all investigated age groups in relation to the youngest cohort (20–29 yrs) for males (above) and females (below) separately. The youngest accomplice is normalised to 'naught' as a reference. The ruby-red surface area highlights the pattern of the absolute modify between the oldest and youngest cohort. (C): Relative change in the segmental RoE for the Epionics segments S1 to S6 betwixt the oldest and youngest age groups for males (above) and females (below) separately. The youngest cohort is normalised to 100% as a reference. Values signal the percentage of the RoE the oldest cohort possesses in relation to the youngest cohort. The red expanse highlights the pattern of the relative changes between oldest and youngest cohorts.

https://doi.org/ten.1371/journal.pone.0116186.g006

Give-and-take

This study investigated the issue of age and sexual practice on the lordosis and the RoM of the whole lumbar spine too as for different lumbar sub-regions in asymptomatic volunteers across the developed lifespan. The results of the present study emphasise the importance of the factor historic period on the lumbar lordosis and the RoM. We demonstrated that the age-related changes in the lordosis and the RoM differ between men and women and are strongly level dependent. The lordosis and RoM in the eye part of the lumbar spine are dominantly reduced with aging, with less reduction towards the lumbo-sacral and thoraco-lumbar transitions. The sex affects only the RoE.

The loss of total lordosis with aging every bit demonstrated in this study (Fig. 4) is in agreement with measurements in the literature [9], [11], [17] and corroborates our commencement hypothesis. This study provides evidence that this aging process is not uniform throughout lifespan and differs between males and females. In both sexes, the decrease of lordosis appears only marginal betwixt 20–29 yrs and 30–39 yrs. While in females the process of aging is later more than continuous, the loss of lordosis in males generally occurs between the 30–39 yrs and 40–49 yrs age groups. This discontinuous loss of lordosis explains why in some studies, in which only cohorts older than forty years with no young control group were investigated, no significant loss of lordosis was found [xiv], [xx]. In the present written report, a high inter-bailiwick variability was constitute, which necessitates a sufficient accomplice size with a homogeneous limerick to detect these historic period effects. Furthermore, in the present study, asymptomatic subjects were investigated, whereas in other studies subjects with acute or chronic depression back hurting participated. However, the change in lordosis during aging differs between asymptomatic and symptomatic subjects, because the latter may already have, for example, a flat sagittal alignment or spinal diseases that afflicted the spinal curvature during an earlier stage of life [1]–[three]. Like to the lordosis in standing, aging is too the crucial cistron for a reduction in total RoM, especially in extension, where it is reduced by 31% betwixt the oldest and youngest cohorts. This is consistent with previous studies [38], [39], [45].

In opposite to our third hypothesis, the lumbar lordosis was non significantly different between both sexes, which is in agreement with several studies [nine], [14], [24], [26], however in opposite to other investigations [12], [46]. The nowadays study suggests that the deviation in lordosis betwixt men and women is small-scale and varies betwixt age groups. This might partly explain why studies with varying cohort sizes and unlike mean ages show contradictory results. Furthermore, in this sample, only subjects with a BMI <26.0 kg/grand² participated, which resulted in a mean BMI of 22.v kg/m². Therefore, the impact of being overweight or obese was not investigated.

Currently, a detailed investigation of the age result on certain regions of the lordosis and its movement is lacking in the literature. In accordance with our second hypothesis, the lower Epionics segments were less affected by aging than the middle segments, which characteristically changes the total lordosis and 'concentrates' the lordotic shape of the lumbar spine to the lower segments. Only one radiological written report on a modest cohort supports our findings of a significant correlation between age and lordosis loss restricted to the middle lordosis (L3–4) [ix]. Only a trend was observed in the adjacent segments L2–iii and L4–5, and no pregnant influence was found in L5–S1. Previous studies reported a shut relationship between the morphology of the pelvis, as, for instance, characterised by the pelvic incidence [47], and the degree of total lumbar lordosis [25], [26], [48], [49]. The level specific changes in lumbar lordosis during crumbling advise that different parts of the lumbar spine may substantially alter their relationship to the individual pelvic incidence.

In analogy to the aging process of the lordosis, the RoM characteristically changes with age. The RoM in the heart lumbar lordosis also decreases, whereas the RoM next to the thoracic and sacral transitions only shows a small change. Therefore, not just the lower lumbar lordosis but also its mobility is preserved during aging. These facts may take important implications for the spinal loading and the prevalent degeneration procedure in the lower lumbar spine during life, and could help to understand the mechanical challenges the lower lumbar spine has to withstand. All the same, these results besides have consequences for the treatment of degenerative spinal diseases. Because the shape and motion differently change for sure regions of the lumbar spine, an age- and lumbar level-specific treatment may be important for long-term patient satisfaction.

This study emphasises that a reduction of the lordosis in symptomatic subjects with a severe, painful degenerated lumbar spine partly consists of a natural adaptive procedure during aging, which as well occurs in asymptomatic subjects. Knowledge of this physiological loss of lordosis in asymptomatic individuals may, however, be essential for surgical reconstruction concepts of the sagittal alignment of the spine. In these concepts, the caste of lordosis is estimated mostly with the help of the individual pelvic incidence of the patient, which is assumed to be independent of posture and historic period (e.1000.: lumbar lordosis  =  pelvic incidence ±9°; [fifty]). Because of the physiological loss of lordosis with crumbling, the relationship between the lumbar lordosis and pelvic incidence appears to also be dependent on historic period. Therefore, an optimal patient-specific reconstruction may require an age dependent estimation of the lordosis.

Although the results presented here are consistent with radiological measurements, information technology should be noted that the Epionics SPINE system determines the curvature of the back and not directly the shape of the spine. Multiple studies previously demonstrated that the curvature and movement measured on the dorsum and the spine significantly correlate with each other [42], [51], [52]. In our own preliminary validation studies, we could additionally testify that the correlation betwixt the back and spinal shape is poor in overweight and obese persons, which limits this study to normal-weight subjects (BMI <26.0 kg/grandⁱⁱ). However, this report investigated the spinal shape and motion of a large asymptomatic cohort for which a radiological report pattern is ethically not supportable. Furthermore, this study is limited by investigating the motion only in the sagittal plane, although the motion of the lumbar spine in other anatomical planes such as during axial rotation and lateral bending might be affected by aging also.

In decision, this study characterises the adaptive response of the lumbar spinal shape and its mobility as a office of historic period in asymptomatic males and females. While the lower function of the lumbar spine retains its lordosis and mobility, the heart function flattens and becomes less mobile. This may take important implications for the clinical long-term success of different surgical interventions, for instance for the surgical reconstruction of the sagittal alignment. Furthermore, the results tin can assistance to better understand the incidence of level- and age-dependent spinal disorders, and are essential for patient specific treatments and an prove-based distinction betwixt painful degenerative pathologies and asymptomatic crumbling.

Acknowledgments

The authors give thanks the volunteers for their contribution to this study.

Writer Contributions

Conceived and designed the experiments: MD AR HS. Performed the experiments: MD LA AR HS. Analyzed the data: Md LA AR EP MB TZ GD CD PS MP HS. Wrote the newspaper: MD LA AR EP MB TZ GD CD PS MP HS.

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