Classification of lumbopelvic pain disorders--why is it essential for management?
- SourceAvailable from: Wim Dankaerts[show abstract] [hide abstract]
ABSTRACT: A comparative study. To investigate sitting postures of asymptomatic individuals and nonspecific chronic low back pain (NS-CLBP) patients (pooled and subclassified) and evaluate the importance of subclassification. Currently, little evidence exists to support the hypothesis that CLBP patients sit differently from pain-free controls. Although classifying NS-CLBP patients into homogeneous subgroups has been previously emphasized, no attempts have been made to consider such groupings when examining seated posture. Three angles (sacral tilt, lower lumbar, and upper lumbar) were measured during "usual" and "slumped" sitting in 33 NS-CLBP patients and 34 asymptomatic subjects using an electromagnetic measurement device. Before testing, NS-CLBP patients were subclassified by two blinded clinicians. Twenty patients were classified with a flexion motor control impairment and 13 with an active extension motor control impairment. No differences were found between control and NS-CLBP (pooled) patients during usual sitting. In contrast, analyses based on subclassification revealed that patients classified with an active extension pattern sat more lordotic at the symptomatic lower lumbar spine, whereas patients with a flexion pattern sat more kyphotic, when compared with healthy controls (F = 19.7; df1 = 2, df2 = 63, P < 0.001). Further, NS-CLBP patients had less ability to change their posture when asked to slump from usual sitting (t = 4.2, df = 65; P < 0.001). Differences in usual sitting posture were only revealed when NS-CLBP patients were subclassified. This highlights the importance of subclassifying NS-CLBP patients.Spine 03/2006; 31(6):698-704. · 2.16 Impact Factor
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ABSTRACT: The aim of this pilot study was to examine whether differences existed in spinal kinematics and trunk muscle activity in cyclists with and without non-specific chronic low back pain (NSCLBP). Cyclists are known to be vulnerable to low back pain (LBP) however, the aetiology of this problem has not been adequately researched. Causative factors are thought to be prolonged forward flexion, flexion-relaxation or overactivation of the erector spinae, mechanical creep and generation of high mechanical loads while being in a flexed and rotated position. Nine asymptomatic cyclists and nine cyclists with NSCLBP with a flexion pattern disorder primarily related to cycling were tested. Spinal kinematics were measured by an electromagnetic tracking system and EMG was recorded bilaterally from selected trunk muscles. Data were collected every five minutes until back pain occurred or general discomfort prevented further cycling. Cyclists in the pain group showed a trend towards increased lower lumbar flexion and rotation with an associated loss of co-contraction of the lower lumbar multifidus. This muscle is known to be a key stabiliser of the lumbar spine. The findings suggest altered motor control and kinematics of the lower lumbar spine are associated with the development of LBP in cyclists.Manual Therapy 12/2004; 9(4):211-9. · 2.24 Impact Factor
- Towards a clinical validation of a classification method for non specific chronic low back pain patients with motor control impairment..
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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