Classification of lumbopelvic pain disorders--why is it essential for management?
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ABSTRACT: Non-specific low back pain (NSLBP) accounts for over 85% of all low back pain. Homogenous subgroups may exist within this diagnosis. This study derived a clinical examination and evaluated the examination's ability to identify homogenous subgroups in NSLBP. Patients with NSLBP were examined using a standardized clinical examination. Each patient was examined by two physiotherapists. Data were analysed for item reliability and the presence of distinct subgroups using cluster analysis. Cross-validation of the clusters identified was conducted. Three hundred and one patients were examined. The inter-tester reliability of the majority of items was moderate to substantial (52% of items with kappa > 0.40). A K-means cluster analysis of the two data sets revealed agreement on the presence of two subgroups. One group (n = 47, 16%) had higher fear avoidance beliefs, anxiety and disability. They were more likely to be provoked by pain provocative tests. They were also more likely to be judged as having central sensitization and a dominant psychosocial component to their presentation. The identification of a group of hypervigilant NSLBP patients should allow the interventions to be targeted towards this group. A valid, standardized clinical examination does contribute to the diagnostic management of NSLBP.Physiotherapy Research International 06/2012; 17(2):92-100.
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ABSTRACT: A cross-sectional study between subgroups of nonspecific chronic low back pain (NSCLBP) and asymptomatic controls. To investigate NSCLBP subgroup differences in spinal position sense and trunk muscle activity when repositioning thoracic and lumbar spine into neutral (midrange) spinal position during sitting and standing. Patients with NSCLBP report aggravation of symptoms during sitting and standing. Impaired motor control in NSCLBP, associated with sitting and standing postures nearer the end range of spinal motion, may be a contributing factor. Rehabilitation improving neutral (midrange) spinal position control is advocated. Postural and motor control alterations vary in different NSCLBP subgroups, potentially requiring specific postural interventions. There is limited evidence on whether subgroup differences exist when performing neutral spine position tasks. Ninety patients with NSCLBP and 35 asymptomatic controls were recruited. Two blinded practitioners classified NSCLBP into subgroups of active extension pattern and flexion pattern. Participants were assisted into neutral spine position and asked to reproduce this position 4 times. Absolute, variable, and constant errors were calculated. Three-dimensional thoracic and lumbar kinematics quantified the repositioning accuracy and surface electromyography assessed back and abdominal muscles activity bilaterally. Irrespective of subclassification, patients with NSCLBP produced significantly greater error magnitude and variability than the asymptomatic controls, but subgroup differences were detected in the error direction. Subgroup differences in the trunk muscle activity were not consistently identified. Although both subgroups produced significantly higher abdominal activity, subclassification revealed difference in superficial multifidus activity during standing, with flexion pattern producing significantly greater activity than the asymptomatic controls. Subgroups of NSCLBP had similar neutral spinal position deficits regarding error magnitude and variability, but subclassification revealed clear subgroup differences in the direction of the deficit. The trunk muscle activation was shown to be largely nondiscriminatory between subgroups, with the exception of superficial lumbar multifidus.Spine 10/2011; 37(8):E486-95. · 2.16 Impact Factor
Article: Stratified models of care.[show abstract] [hide abstract]
ABSTRACT: Stratified care for back pain involves targeting treatment to subgroups of patients based on their key characteristics such as prognostic factors, likely response to treatment and underlying mechanisms. It aims to tailor therapeutic decisions in ways that maximise treatment benefit, reduce harm and increase health-care efficiency by offering the right treatment to the right patient at the right time. From being called the 'Holy Grail' of back pain research over a decade ago, stratified care is becoming the zeitgeist in research and clinical practice. In this chapter, we introduce and evaluate the quality and underpinning evidence for three examples of stratified care for back pain to highlight their general principles, research design issues and clinical practice implications. We include consideration of their merits for implementation in practice. We conclude with a set of remaining, key research questions.Best practice & research. Clinical rheumatology 10/2013; 27(5):649-61. · 2.90 Impact Factor
1. The first group appears to be represented by subjects
where the movement impairment and motor dys-
function is secondary to an underlying pathological
process such as inflammatory pain disorders, neuro-
Manual Therapy ] (]]]]) ]]]–]]]
Classification of lumbopelvic pain disorders—Why is it essential for
Curtin University of Technology, School of Physiotherapy, GPO Box U1987, Perth WA 6845, Australia
The majority of lumbopelvic pain disorders have no
diagnosis leaving a management vacuum. The classifica-
tion of lumbopelvic pain disorders into subgroups is
considered one of the greatest challenges, so as to enable
the application of specific and effective interventions. It
is well acknowledged that chronic lumbopelvic pain
disorders are complex and multi-dimensional in nature.
These disorders are commonly associated with changes
in neurophysiology, altered motor control, psychologi-
cal factors such as fear and anxiety, faulty coping
strategies, social impact and in some cases pathoanato-
mical factors (Waddell, 2004). There is considerable
debate as to the significance of these different factors
and what is cause and effect.
There is a growing focus within physiotherapy to treat
motor control impairments associated with these dis-
orders. Altered motor control in CLBP disorders is
complex, highly variable and individual in nature.
Trunk motor control is influenced by: spinal–pelvic
posture, movement, stability demand, respiration and
continence demand as well as neurophysiological
factors, pathology and various psychological factors.
Altered motor control may be adaptive (protective) or
mal-adaptive (provocative). It can result in excessive
spinal stability and increased spinal loading (due to
muscle guarding and splinting) or reduced spinal
stability (inhibition of spinal stabilizing muscles) leading
to pain (O’Sullivan, 2005).
It is proposed that there are three main groups that
present with chronic disabling lumbopelvic pain with
regard to motor control impairments (O’Sullivan, 2005).
genic pain, neuropathic or centrally mediated pain
disorders, severe structural disorders.
2. A second group exists where a dominance of
psychological and/or social (non-organic) factors
are the underlying drive behind the disorder. This
results in altered central processing, amplification of
pain, and resultant disordered movement and motor
In these two groups, attempts to simply normalize
the motor dysfunction and movement impairment
does not result in resolution of the disorder and is
likely to fail.
3. It is proposed that a third group exists where mal-
adaptive movement and motor patterns result in
chronic abnormal tissue loading and ongoing pain
and distress. This group appears to present in two
(a) Pain disorders associated with ‘movement im-
pairment’ classification are characterized by
avoidant pain behaviour and are associated with
a loss of normal physiological lumbopevic
mobility in the direction of pain. These disorders
present with abnormally high levels of muscle
guarding and co-contraction of lumbopelvic
muscles. This results in abnormally high levels
of compressive loading across articulations,
excessive stability and hence movement restric-
tion as well as muscle strain and fatique. This is
usually accompanied by fear of moving into the
painful impairment, as well as faulty cognitive
coping strategies and beliefs regarding the pain
disorder. This represents a mal-adaptive re-
sponse to a pain disorder and a mechanism for
ongoing pain and disability.
Management of this group is based on a cognitive
ARTICLE IN PRESS
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1356-689X/$-see front matter r 2006 Elsevier Ltd. All rights reserved.
behavioural model. The aim is to reduce fear of
movement and reduce muscle tone by education
and facilitating graduated movement exposure
into the painful range in a relaxed and normal
(b) Pain disorders associated with ‘control impair-
ment’ classification are associated with no
impairment to the mobility of the symptomatic
spinal segment in the direction of pain provoca-
tion. Rather they present with impairments in
the control of the symptomatic spinal segment in
the direction of pain. This is associated with
deficits in motor control with the inability to
effectively control the neutral zone of the motion
segment or fix the spinal segment at an end range
provocative positions. This appears to result in
pain secondary to recurrent end range strain and
non-physiological spinal segment movement and
loading. These patients adopt postures and
movement patterns that are mal-adaptive, pro-
vocative (not avoidant) and represents a me-
chanism for ongoing pain and disability.
A motor learning intervention based on a cognitive
behavioural treatment model with the aim of changing
faulty movement behaviour that is linked to the pain
disorder is advocated for these disorders.
There is growing evidence to support the presence of
these sub-groups of patients leading to effective targeted
interventions (O’Sullivan, 2000, 2004, 2005; O’Sullivan
et al., 2002, 2003, 2005; Burnett et al., 2004; Elvey and
O’Sullivan, 2004; Dankaerts et al., 2005a,b).
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