Comparing lumbo-pelvic kinematics in people with and without back pain: A systematic review and meta-analysis

Abstract

Background
Clinicians commonly examine posture and movement in people with the belief that correcting dysfunctional movement may reduce pain. If dysfunctional movement is to be accurately identified, clinicians should know what constitutes normal movement and how this differs in people with low back pain (LBP). This systematic review examined studies that compared biomechanical aspects of lumbo-pelvic movement in people with and without LBP.

Methods
MEDLINE, Cochrane Central, EMBASE, AMI, CINAHL, Scopus, AMED, ISI Web of Science were searched from inception until January 2014 for relevant studies. Studies had to compare adults with and without LBP using skin surface measurement techniques to measure lumbo-pelvic posture or movement. Two reviewers independently applied inclusion and exclusion criteria, and identified and extracted data. Standardised mean differences and 95% confidence intervals were estimated for group differences between people with and without LBP, and where possible, meta-analyses were performed. Within-group variability in all measurements was also compared.

Results
The search identified 43 eligible studies. Compared to people without LBP, on average, people with LBP display: (i) no difference in lordosis angle (8 studies), (ii) reduced lumbar ROM (19 studies), (iii) no difference in lumbar relative to hip contribution to end-range flexion (4 studies), (iv) no difference in standing pelvic tilt angle (3 studies), (v) slower movement (8 studies), and (vi) reduced proprioception (17 studies). Movement variability appeared greater for people with LBP for flexion, lateral flexion and rotation ROM, and movement speed, but not for other movement characteristics. Considerable heterogeneity exists between studies, including a lack of detail or standardization between studies on the criteria used to define participants as people with LBP (cases) or without LBP (controls).

Conclusions
On average, people with LBP have reduced lumbar ROM and proprioception, and move more slowly compared to people without LBP. Whether these deficits exist prior to LBP onset is unknown.

Full text

R E S E A R C H A R T I C L E Open Access
Comparing lumbo-pelvic kinematics in people
with and without back pain: a systematic review
and meta-analysis
Robert A Laird
1,5*
, Jayce Gilbert
2
, Peter Kent
3,4
and Jennifer L Keating
1
Abstract
Background: Clinicians commonly examine posture and movement in people with the belief that correcting
dysfunctional movement may reduce pain. If dysfunctional movement is to be accurately identified, clinicians
should know what constitutes normal movement and how this differs in people with low back pain (LBP). This
systematic review examined studies that compared biomechanical aspects of lumbo-pelvic movement in people
with and without LBP.
Methods: MEDLINE, Cochrane Central, EMBASE, AMI, CINAHL, Scopus, AMED, ISI Web of Science were searched
from inception until January 2014 for relevant studies. Studies had to compare adults with and without LBP using
skin surface measurement techniques to measure lumbo-pelvic posture or movement. Two reviewers independently
applied inclusion and exclusion criteria, and identified and extracted data. Standardised mean differences and 95%
confidence intervals were estimated for group differences between people with and without LBP, and where possible,
meta-analyses were performed. Within-group variability in all measurements was also compared.
Results: The search identified 43 eligible studies. Compared to people without LBP, on average, people with LBP
display: (i) no difference in lordosis angle (8 studies), (ii) reduced lumbar ROM (19 studies), (iii) no difference in lumbar
relative to hip contribution to end-range flexion (4 studies), (iv) no difference in standing pelvic tilt angle (3 studies), (v)
slower movement (8 studies), and (vi) reduced proprioception (17 studies). Movement variability appeared greater for
people with LBP for flexion, lateral flexion and rotation ROM, and movement speed, but not for other movement
characteristics. Considerable heterogeneity exists between studies, including a lack of detail or standardization
between studies on the criteria used to define participants as people with LBP (cases) or without LBP (controls).
Conclusions: On average, people with LBP have reduced lumbar ROM and proprioception, and move more slowly
compared to people without LBP. Whether these deficits exist prior to LBP onset is unknown.
Keywords: Low back pain, Movement disorders, Posture, Range of movement, Lordosis, Proprioception
Background
Observation of lumbo-pelvic movement and posture is a
basic component of the physical examination of people
with low back pain (LBP) [1-4] partly due to a common
belief held by clinicians that identifying and correcting
movement/postural aberration can improve pain and
activity limitation [2,5,6]. Examination of lumbo-pelvic
movement typically includes basic kinematic assessments,
such as range of movement (ROM) and posture. It may
also include higher order kinematics such as temporal and
sequential patterns during physiological movements,
proprioception, muscle activation patterns, postural sway
and/or complex functional movements such as walking or
lifting. If clinicians aim to ‘normalise’dysfunctional move-
ment, they need an empirical basis for (i) differentiating
between normal and dysfunctional movement, and (ii) de-
termining whether correction of dysfunctional movement
might reduce pain and activity limitation. Measurement of
movement and posture has been problematic in typical
clinical settings due to limitations (practicality, accuracy,
* Correspondence: robert.laird@monash.edu
1
Department of Physiotherapy, Monash University, PO Box 527, Frankston,
VIC 3199, Australia
5
7 Kerry Rd, Warranwood, Melbourne, VIC 3134, Australia
Full list of author information is available at the end of the article
© 2014 Laird et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Laird et al. BMC Musculoskeletal Disorders 2014, 15:229
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comprehensiveness, reliability) of simple measurement
tools such as goniometers, tape measures and inclinometers
[7]. Advances in technology are creating new opportunities,
available for use in typical clinical settings, that measure
comprehensive information about the relationship between
movement/posture and pain [8-10].
Measurements reported in studies of lumbo-pelvic
kinematics, such as ROM, vary considerably. This variabil-
ity may be due to differences in measurement instruments
or methods [11], biological differences in true range of
movements, or errors in measurements. Intolo [12], in a
systematic review into the effect of age on ROM, per-
formed a meta-analysis of mean scores for lumbar ROM
for 20-29 year olds. Across studies, the lowest reported
group mean score for flexion was 24 ± 7° [13] while the
highest was 75 ± 10° [14]. Similarly, mean scores for exten-
sion ranged from 13 ± 8° [13] to 41 ± 10° [15]. These large
differences between studies are unlikely to be due to bio-
logical differences alone. Milosavljevic et al. [13] provided
ROM estimates using a photographic method, Russell
et al. [14] used an Isotrak system and Fitzgerald et al. [15]
used a tape-measure (Schober) method [16]; such method
differences are likely to account for a large proportion
of observed differences. Similar variation is seen for
axial rotation and lateral flexion movements. Extreme
variations in reported ROM measurements limit confi-
dence in clinical interpretations or treatment decisions
based on measurements of an individual.
A search for reviews on what is known about typical
movement in people with and without LBP identified
one review on postural sway [17], and one review on
age-related changes to lumbar spine ROM [12]. The
qualitative review on postural sway, reported that 14 of
16 included papers concluded that people with LBP
have greater postural sway excursion when compared to
people without LBP. The review on age-related change
to lumbar ROM reported a reduction in ROM associated
with increasing age but did not include people with LBP
and did not report mean ROM data. No reviews were
foundcomparingpeoplewithandwithoutLBPonany
other movement characteristics. Therefore, we designed
this review to systematically investigate and compare typical
lumbo-pelvic movement differences between people with
and without LBP, focusing on ROM, movement sequence
and speed, a movement related measure of proprioception
(positioning/re-positioning accuracy), pelvic tilt angles (in
standing and sitting), and segmental body contributions to
movement (lumbar versus hip contributions). We also
compared differences in variability between the two groups.
Methods
Study selection: inclusion and exclusion criteria
For inclusion in the review, studies had to (i) assess
adults >17 years; (ii) use non-invasive measurement
systems (i.e. did not use measurements such as X-rays,
CT scans); (iii) apply the same procedures to measure
people with low back +/-leg pain (LBP group) and
people without LBP (NoLBP group), (iv) measure at
least one of lumbar lordosis, lumbar range of motion
(ROM), speed/acceleration/timing of lumbar +/- hip
movement, pelvic tilt angle (as measured by a line drawn
from anterior to posterior superior iliac spines with an
angle formed relative to horizontal, measured in sitting or
standing), pelvic tilt ROM (defined as a range from
maximum anterior tilt to maximum posterior tilt), usual
sitting pelvic tilt position (i.e. relative to full anterior
tilt), lumbar compared with hip contributions to ROM,
lumbo-pelvic proprioceptive position/re-position accur-
acy; (v) report appropriate measurement means (or other
point estimates) and variance estimates or data that enable
estimation of these values. In order to fully survey pub-
lished research on lumbo-pelvic movement, no specific
definitions of back pain or control (NoLBP) groups were
required but the definitions of LBP group, pain intensity
and NoLBP group within each study were extracted. Stud-
ies were excluded if they (i) included people who had lum-
bar surgery in the previous 12 months; (ii) reported that
subjects had fracture, neurological conditions, metabolic
disease, neoplasm, or scoliosis; (iii) measured only whole
body movement such as distance from finger-tip-to-floor
or (iv) reported insufficient data, e.g. did not report mea-
sures of variability. Lead authors were contacted to obtain
additional data as required.
Data sources
Eight electronic databases (MEDLINE, Cochrane Central
Register of Controlled Trials (Central), EMBASE, AMI,
CINAHL, Scopus, AMED, ISI Web of Science) were
searched from inception until January 2014 using a broad
search strategy based on relevant medical subject heading
(MeSH) terms [18] (see Additional file 1). The search yield
was initially screened for eligibility by one reviewer (RL)
on title and abstract to remove duplicates and clearly un-
related articles. Following this, two reviewers (RL and JG)
independently identified potentially relevant articles based
on title and abstract. Full text articles were retrieved and
checked for compliance with inclusion and exclusion cri-
teria. References of potentially relevant reports were
reviewed for additional papers. Consensus by discussion
was then reached on article inclusion. Where disagree-
ment occurred, a third reviewer (JK) was included and
discussion continued until consensus was achieved. A flow
diagram of the study selection process based on PRISMA
recommendations [19] is seen in Figure 1.
Data extraction and study quality assessment
A checklist for data extraction was developed based on
those used in a similar review [12] and published quality
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assessment tools [20-22]. The following study details
were extracted: participant age, sex, and source charac-
teristics, inclusion/exclusion criteria, training of testers
(profession, experience), measurement methods and pro-
cedures (instrument used, instructions to participants,
position of testing), the movement characteristics assessed
(e.g. range, speed, relative contributions of body seg-
ments), pain/function measures, measurements for those
with and without back pain (e.g. means, standard devia-
tions). A quality assessment tool, using a similar approach
to Mieritz [23], was constructed to determine how each
study accounted for possible sources of bias, and if the
study provided details on: (i) study population (age, sex,
BMI, source), (ii) participant LBP (chronicity, +/- leg pain,
specific versus non-specific, pain intensity and activity
limitation scores), (iii) measurement procedures (i.e. detail
that would enable accurate replication of the experiment,
instrument description, standardised movement instruc-
tions, movement process description e.g. fixed or free pel-
vis), (iv) blinding of assessors to the presence of back pain
(yes/no), and (vi) whether the same assessment proce-
dures were applied to participants with and without back
pain (see Additional file 2). Two reviewers independently
extracted data, compared results and resolved differences
through discussion.
Data synthesis and analysis
Study details were extracted and summarised (Additional
files 3 and 4). For each comparison, standardised mean
differences (SMD) between groups with and without LBP
were calculated using Revman software [24]. Pooled esti-
mates of overall differences were calculated by meta-analysis
of studies that measured a kinematic characteristic using
comparable methods. For example studies on flexion
ROM were included in a meta-analysis if subjects were
standing using angular measurement but excluded if sub-
jects were in other positions (i.e. four point kneeling) or if
linear/distance measurements were used. Reasons for
exclusion from meta-analysis are found in Additional
file 3. A random effects model was used for pooling
where fixed effects modeling indicated statistical heterogen-
eity of the data (Mantel-Haenszel method), as determined
by chi-squared and I
2
statistics; otherwise the results of
fixed effects modeling was reported [25,26].
Figure 1 Flow diagram of study inclusion.
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We also planned to explore the within-group variability
in each measured movement characteristic. To estimate
whether variability for each movement characteristic dif-
fered between groups with and without LBP, a coefficient
of variation (CoV) [27] (standard deviation in measure-
ments divided by the group mean) was calculated for each
movement parameter using those studies included in the
relevant meta-analysis. CoVs were averaged after weight-
ing for sample size. Differences between groups were ex-
amined by creating a ratio of weighted averages where
ratios >1 indicate greater variability for those with LBP
and ratios <1 indicate greater variability for those without
LBP. Significant differences in pooled CoVs were exam-
ined by estimating 95% confidence intervals for observed
ratios. The correlation (Pearson’s r) between effect size
and study quality was calculated using STATA (version 12,
Stata Corp, College Station, Texas USA).
Results
Search yield
The search identified 17,276 potentially relevant articles
with 13 articles identified from bibliographies of related
articles or other sources. Following screening of title and
abstract, full texts of 86 articles were retrieved. Forty
three studies (45 articles) met the inclusion criteria
[28-70]. The study selection process is shown in Figure 1.
A summary of included studies can be seen in Additional
file 3. A list of studies retrieved in full text and subse-
quently excluded, and reasons for exclusion, are available
from the first author on request.
Types of studies found
Included studies were grouped in categories: lordosis
[31,32,38,47-49,57,58], range of movement (ROM) [29,30,
34,37-42,44,47,50-54,56-59,69,71], relative hip and lumbar
contribution to trunk flexion/extension [34,40,50,52,61,71],
pelvic angle/relative position and ROM [31,32,57,58],
speed/acceleration of lumbar movement [28,34,37,39,41,
42,50,71], and proprioception (repositioning accuracy)
[33,35,45,46,53,55,60-68,70,72]. Additional file 4 sum-
marises the characteristics of included studies.
Definition of LBP and NoLBP groups
Case definition (LBP) Of the 43 studies included, 48%
provide no detail on diagnostic criteria, 37% defined their
LBP participants as non-specific, and the remaining 15%
used either a Quebec [73] or a movement based classifica-
tion (see Additional file 5 for details). Fifty-six percent
reported pain intensity scores.
Control definition (NoLBP) A definition of control
participants was provided by 60% of the 43 studies. Those
definitions were highly variable, ranging from vague de-
scriptions such as ‘no current pain’(16%), six-months
(14%), 12-months (14%) or 24-months (7%) pain free to
‘no LBP ever’(9%).
Quality assessment
Table 1 lists the domains identified as potential sources
of bias in the included studies and the percentage com-
pliance with each item. No studies attempted blinding of
assessors to group status, and only one study reported
standardizing instructions to participants. The potential
influence of study quality on reported differences between
groups was examined for all groups. There was no signifi-
cant correlation observed between total quality assessment
scores and the magnitude of SMDs in measurements for
those with and without LBP (r = 0.03), There was also no
significant difference between individual items of quality as-
sessment and the size of SMD. Results for individual studies
are available in Additional file 5.
Movement characteristics
Lordosis
A meta-analysis of eight studies comparing lumbar lordosis
angle in people with and without LBP when standing is
presented in Figure 2. Most studies reported small,
non-significant differences between groups. The pooled
difference (SMD = 0.01, 95% CI -0.09 to 0.11, p = 0.89)
was not significant. A post-hoc meta-analysis of three
studies that compared genders indicated that women had
greater lordosis angles than men (SMD = 0.92, 95% CI 0.8
to 1.05, p < 0.01).
Range of motion (ROM)
Meta-analyses of 26 ROM studies consistently found
reduced range of movement of the lumbar spine in
people with LBP. Figures 3, 4, 5 and 6 summarise the
findings for flexion, extension, lateral flexion and rota-
tion meta-analysis. Where studies measured bilateral
movement, i.e. left and right rotation, weighted means
and standard deviations were averaged. In some included
studies, measurements from a single group without LBP
were compared with a number of LBP groups, such as
men and women or acute and chronic LBP. As the ob-
served differences may not satisfy the statistical assump-
tion of independence required for meta-analysis [74], the
sample size of these groups without LBP used in the
meta-analysis were divided by the number of comparisons
made. Means and standard deviations (SD) are in degrees
of movement.
Lumbar spine versus hip contribution to flexion/extension
Six studies examined the relative lumbar and hip contri-
bution to flexion movements, five [34,50,52,61,71] during
forward flexion, and one [40] returning from a fully flexed
position. Four of five studies investigating forward flexion
found no significant difference between those with and
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without LBP when comparing lumbar with hip contri-
bution (ratio) to flexion ROM at end range. A non-
significant but consistent effect favored reduced lumbar
(compared with hip) contribution to flexion (Figure 7) for
those with LBP (SMD = -0.21, 95% CI -0.52 to 0.09, p =
0.17). Three studies [34,40,52] found significant differences
in the ‘through-range’contribution of lumbar movement.
Esola et al. [34] (SMD = -0.86, 95% CI -1.51 to -0.22) and
Porter et al. [52] (SMD = -0.71 95% CI -1.43 to 0.00) both
found significant reductions of lumbar contribution to mid-
range flexion but not at end range. McClure et al. [40]
found a greater contribution of the lumbar spine during
mid-range return from the fully flexed position (relative
extension) (SMD = 0.95 95% CI 0.10 to 1.81).
Pelvic tilt angle, relative position and tilt range
Three studies (four articles) examined usual pelvic tilt
angle in standing [31,32,57,58]. No significant differences
were found between people with or without LBP for any
study (see Table 1 for details). A small, non-significant
but consistent effect favouring greater anterior pelvic tilt
in people with LBP was evident when studies were pooled
in meta-analysis (see Figure 8). Only Day et al. [32] com-
pared differences between groups with and without LBP
in full anterior and posterior tilt positions, and found a
significant difference for maximum anterior tilt angle
(higher angle for people with LBP) :SMD = 0.73 (0.09 to
1.35, p = 0.02), but not maximum posterior tilt angle:
SMD = 0.09 (-0.53 to 0.7, p = 0.78)).
Speed/Acceleration
Seven studies measured speed [34,37,39,43,50,71,75] and
one measured acceleration [28]. Data on lumbar flexion
speed/acceleration differences between groups with and
without LBP were combined in meta-analysis (Figure 9).
A large, significant effect of slower movement in the
Table 1 Quality assessment summary (see Additional files 2 and 5 for item decision rules and scores for each
included study)
Quality assessment domains Percentage of studies scoring yes
Selection bias
1. Was the study population adequately described? 57%
2. Where both groups drawn from the same population? 39%
3. Were both groups comparable for age, sex, BMI/weight 54%
4. Was pain intensity and/or activity limitation described for LBP group? 56%
5. Was an attempt made to define back pain characteristics? 34%
Measurement and outcome bias
6. Did the method description enable accurate replication of the measurement procedures 90%
7. Was the measurement instrument adequately described? 95%
8. Was a system for standardising movement instructions reported? 37%
9. Were assessors trained in standardised measurement procedure? 2%
10. Did the same assessors test those with and without back pain 17%
11. Were assessors blinded as to which group subjects were in? 0%
12. Was the same assessment procedure applied to those with and without back pain? 93%
Data presentation
13. Were between-group statistical comparisons reported for at least one key outcome 94%
Figure 2 Studies comparing lordosis in LBP versus NoLBP groups. Means & standard deviations (SD) are in degrees with the exception of
Day et al. [32] who used an algebraic computation based on linear measurement.
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LBP group was evident (SMD -1.46 95% CI -1.96 to -1.02,
p < .01).
Proprioception
Fifteen studies [33,35,45,46,53,55,60,62-68,70,76] mea-
sured position/reposition accuracy as a measure of lumbar
spine proprioception (see Additional files 3, 4 and 6 for
details). Twelve studies [35,45,46,53,60,62-64,68-70,76]
measured absolute error in re-positioning accuracy and
were included in meta-analysis. One study measured
the number of trials required to achieve accurate re-
positioning [33], one measured motion detection, [55]
one measured ability to achieve a described position
[67] and two measured motion precision [65,66] but were
excluded from meta-analysis as data were not comparable.
A consistent, large and significant reduction in ability to
accurately re-position the spine at pre-specified angles for
people with LBP compared to those without LBP is shown
in Figure 10 (SMD = 1.04, 95% CI 0.64 to 1.45, p < 0.01).
The studies included in this review using different types of
assessments that precluded meta-analysis also found sig-
nificant differences indicating reduced proprioception in
the LBP group (26,55). Descarreaux et al. [33] tested if
LBP subjects (divided into two groups according to nor-
mal or slow speed of force production on isometric resist-
ance) compared to subjects without LBP, could accurately
place the lumbar spine into various flexion angles. They
determined that although both LBP and control groups
demonstrated similar re-positioning accuracy, the LBP
subgroup that developed slow isometric force (n = 9 of 16)
required significantly more practice to achieve this
(SMD = 1.87, 95% CI 0.89 to 2.85, p < 0.01). Taimela et al.
[55] reported a significant reduction in the ability of
people with chronic LBP to detect change in lumbar pos-
ition when compared to a group without LBP but did not
include data on variability required for meta-analysis. Field
et al. [67] demonstrated reduced accuracy for people with
LBP in achieving a demonstrated position in flexion when
compared to people without LBP (SMD = 1.66, 95% CI
0.82 to 2.42, p < 0.01). Willigenberg et al. [65,66] also
identified reduced accuracy in both motion control,
(SMD = 1.14, 95% CI 0.39 to 1.89, p < 0.01) and motion
tracking in people with LBP (SMD = 1.08, 95% CI 0.32
to 1.84, p < 0.01).
A summary of standardised mean differences, across
all the kinematic characteristics investigated, is shown in
Table 2.
Differences in variability between groups
Table 3 presents a summary of the within group variability
in movements pooled across studies. Significantly greater
variability for people with LBP compared to people
Figure 3 Flexion ROM meta-analysis.
Figure 4 Extension ROM meta-analysis.
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without LBP was observed on four of the eight measures:
flexion, lateral flexion, rotation and speed/acceleration.
Discussion
This review summarised the results of studies of lumbo-
pelvic kinematics for people with and without LBP. Al-
though the results will be unsurprising to most clinicians, it
is the first review to meta-analyse and quantify the clinical
observation that, on average, people with LBP have reduced
lumbar ROM, move more slowly and have reduced
proprioception compared to with those without LBP.
The review highlights the highly heterogenous nature
of available studies, with six of nine meta-analyses indi-
cating significant between study heterogeneity in results.
Possible sources of heterogeneity between study outcomes
include differences in definitions of back pain, control
characteristics, LBP intensity, and instruments and methods
for measuring movements. This heterogeneity confounds
secondary analyses such as the influence of pain intensity
on observed differences between people with and without
LBP.
The lack of detail or standardized definition for con-
trol subjects is also problematic. For example, it is hypo-
thetically possible that altered movement characteristics
occur as a result of a LBP episode and persist after pain
resolves. If this is the case, people that were pain free
but with persistent altered movements, would have been
eligible as control subjects for many of the included
studies, provided the episode had been prior to the pain-
free time period required for that study. This would have
diluted differences between the groups. Similarly, it is
not known if certain ‘aberrant’movement characteristics
exist prior to the onset of LBP and are risk factors for an
episode of LBP, in which case these characteristics may
have also been present in people classified in the included
studies as control subjects.
No studies attempted to blind assessors to group type,
and a general absence of procedural standardization, such
as movement instruction or assessor consistency, exposes
studies to the potential for random or systematic error.
However, the relative consistency of the direction of re-
sults across studies adds credibility to the findings of this
review, and observed effects appear large enough to be
visible despite potential study limitations.
Lordosis
Lordosis angle does not differentiate people with and
without LBP. A similarly wide range of group means were
reported for those with LBP (23° to 56°) and without LBP
(19° to 53°). This variability might be associated with the
six different measurement methods, but may also reflect
biological differences in sample ethnicity [77], age [78]
and gender [49,57,58]. Increasing age has been associated
with reduced lordosis in the sixth decade [78-80] and
on average, females have a greater lordosis than males
[49,58,80]. Four studies included only males [31,32,38,47]
and it is perhaps understandable that these studies found
the four lowest average lordosis angles. However, this
variability in lordosis appears similar for people with and
without LBP. Therefore, lumbar lordosis when measured
Figure 5 Lateral flexion ROM meta-analysis.
Figure 6 Rotation ROM meta-analysis.
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using surface techniques, does not, on average, appear to
discriminate between people with and without LBP.
Range and speed of motion
Clinicians commonly use ROM [81] to assist in identifying
patterns of dysfunction, and to monitor change. ROM has
been extensively studied by invasive and non-invasive
methods, but non-invasive measurement is better suited
to routine clinical assessment. This review included 20
studies that compared ROM for those with and without
LBP using skin-surface measurement. The pooled sample
was large enough to be confident in the finding that
people with LBP have reduced average lumbar ROM com-
pared to those without LBP. The mean ROM reported for
people without LBP is so variable that it has little refer-
ence value e.g. (considering all studies) flexion: min = 23°,
max = 92°; extension: min = 15°, max = 56°, lateral flexion:
min = 3°, max = 44°; rotation: min = 3°, max = 62°. Large
variations between studies suggest differences beyond
those explained by biological variation and implicate
method differences. Using flexion ROM as an example, 14
studies used nine different measurement devices ranging
in sophistication from simple handheld inclinometers and
flexible rulers to opto-electronic devices. Youdas [57,58]
used a flexible rule measurement technique (mean lumbar
flexion angle = 23 ± 10°) while Hidalgo [37] used an
opto-electronic system (92 ± 15°); both studies used
similar inclusion criteria, and the same starting position.
Other method processes may also contribute to differ-
ences: two studies assessed range in sitting, 10 in relaxed
standing, and two used some form of restricted movement
(harness or fixed pelvic position). Based on these findings,
normative data may have limited relevance to a clinical
environment unless the same measurement methods used
to obtain published data are also used in the clinical set-
ting where they are applied. The lack of clarity about
similarity between study populations and method details
makes the use of pooled group-level estimates of move-
ments, such as mean flexion ROM, unwise. However,
these between-study differences did not obscure consist-
ent within-study findings; eight of 14 studies of flexion
demonstrated significantly less lumbar flexion for those
with LBP and only one study found that lumbar flexion
was significantly greater for those with LBP. These find-
ings of large between study differences in measurements,
and consistent within study differences between those
with and without LBP, are similar for the other move-
ments analysed in this review.
Lower movement speed is commonly seen in people
with LBP, so it is unsurprising to observe in our review
that those with LBP demonstrated significantly slower
speeds when the eight included studies were pooled in
meta-analysis. Reduced speed of lumbar movement has
been linked to fear of movement and has also been
shown to persist after recovery [82].
Lumbar versus hip contribution to movement
Clinicians have reported assessing the relative contribu-
tion of lumbar and hip joints (during flexion and exten-
sion movements) to assist in determining subgroups
within the LBP population that require specific treatment
strategies [83,84]. This review identified six studies that
measured patterns and relative contributions to trunk
flexion from the lumbar spine and hip joints, often de-
scribed as ‘lumbo-pelvic rhythm’. Data could be pooled
for four studies (six comparisons) evaluating ROM of
Figure 7 Meta-analysis of studies investigating the relative contributions of lumbar versus hip ROM through the range of trunk
flexion. Means (and SDs) are ratios of lumbar to hip movement. Zero represents equal lumbar to hip contribution to trunk flexion,
numbers <0 indicate less lumbar compared with hip movement while numbers >0 indicate more hip than lumbar movement.
Figure 8 Meta-analysis of studies comparing pelvic tilt angle in neutral standing.
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http://www.biomedcentral.com/1471-2474/15/229

lumbar and hip contribution at end-range flexion. A
typical pattern of lumbar versus hip movement for both
groups showed less lumbar and greater hip ROM at end-
range flexion, with small, non-significant differences of re-
duced lumbar contribution for the LBP group when com-
pared to people without LBP.
However relative contributions of lumbar spine and
hip to ROM may be less important than patterns of
when and how movement takes place. Nelson-Wong et al.
[84] recently reported that the relative timing of hip and
lumbar movement when arising from a fully flexed pos-
ition differentiated between people who do or do not
develop back pain after two hours of standing. People
who developed pain used a lumbar > hip initiation of
movement (spine moves first followed by pelvic/hip
movement) strategy on arising from the flexed position
while non-pain developers used a hip > lumbar strategy
(p = 0.03). This finding is supported by McClure et al.
[40], Esola et al. [34] and Porter et al. [52] who all reported
relatively greater lumbar through-range contribution in
people with LBP on flexion movement. It may be that
people with LBP can be subgrouped by lumbo-pelvic
rhythm. For example, Kim et al. [61] examined lumbo-
pelvic rhythm by comparing two subgroups of people with
LBP to a group of people without LBP. One subgroup had
pain provoked by flexion/rotation activities and the other
by extension/rotation activity. The flexion-aggravated group
had significantly greater lumbar contribution to flexion
compared to the normal and extension groups. The
extension-aggravated group on the other hand had a
significant pattern of reduced lumbar contribution to
flexion. Lumbar versus hip contributions to movement,
particularly flexion, appear to have clinical relevance
and warrant further exploration.
Pelvic tilt angle, position and range
Extreme (end-range) pelvic tilt angle in standing and sit-
ting has been linked to back pain [85,86] but with limited
evidence. Clinical interventions aiming to modify pelvic
tilt angle to achieve more neutral positions are based on
the assumption that there is a relationship between pos-
ition and pain. There are few studies that explore the rela-
tionship between LBP and typical pelvic tilt range (from
full anterior to full posterior tilt) and the relative position
of pelvic tilt angle during sitting and standing in people
with and without LBP. This review found no differences
when pooling data from three studies that compared
standing pelvic tilt angle in people with and without LBP.
Similarly, Astfalk et al. [85] found no differences in aver-
age lumbar flexion angle in sitting (reflecting pelvic tilt
position) when comparing adolescents with and without
LBP (125.3 ± 19.8° vs 130.6° ± 15.7 respectively). However
significant differences were observed for lumbar flexion
angle when adolescents with LBP were sub-grouped based
on direction of movement that provoked pain. The
flexion-provoked pain group had a significantly greater
Figure 9 Forest plot of speed differences between LBP and NoLBP groups (original units are deg/sec or deg/sec
2
).
Figure 10 Forest plot of position/reposition differences (raw scores in degrees) comparing LBP and NoLBP groups.
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lumbar angle (135.6 ± 16.9°, p < 0.05) compared to those
without LBP while the extension-provoked pain group
had a significantly smaller lumbar angle (113.5 ± 16.3°, p <
0.05) when compared to those without LBP. Sub-grouping
of a LBP population based on the relationship of aggravat-
ing activities and direction of painful movement may dem-
onstrate associations between back pain and pelvic tilt
angle/relative position.
Proprioception
Our meta-analysis of studies measuring one aspect of
proprioception (absolute error during re-positioning trials)
demonstrated a significant and large loss of re-positioning
accuracy in the LBP group. The implications of reduced
proprioception are that people with LBP are less ‘move-
ment-aware’with potentially reduced postural control.
This is consistent with a recent systematic review on
another aspect of proprioception, postural sway, by Ruhe
et al. [17] who found that greater sway excursion and
speed were present in people with LBP compared to
people without back pain.
Differences in variability between people with and
without LBP
Our assessment of differences in variability between people
with and without LBP for nine movement characteristics
demonstrated significantly greater variability for four move-
ment characteristics: flexion, lateral flexion and rotation
ROM, and speed of movement. There were no significant
differences in variability for lordosis, extension ROM,
lumbar versus hip contribution to movement or proprio-
ception. It is not clear if the greater variability seen in the
LBP group is clinically meaningful (10% difference in aver-
age variability estimates) but it raises a question of
whether postures or activities performed using extremes
of certain movement (e.g. excessive or restricted move-
ment) may predispose people to LBP.
This review examined differences in group means for
people with and without LBP. Given the high variability
seen between studies, the small between-group differences
compared with the high within-group differences, and the
greater variability on some movement characteristics
seen in the LBP group, these findings cast some doubt
Table 2 Summary of pooled standardized mean differences
Position and movement differences between people with and
without LBP (number of studies included in meta-analysis)
Standardised mean difference (95% CI)
for all studies suitable for meta-analysis
Lordosis*, n = 8 0.01 (-0.09 to 0.11), p = 0.89
Flexion**, n = 14 -0.62 (-0.94 to -0.29), p < 0.01
Extension**, n = 9 -0.54 (-0.81 to -0.27), p < 0.01
Lateral Flexion**, n = 9 -0.73 (-1.14 to -0.33), p < 0.01
Rotation**, n = 9 -0.49 (-0.76 to -0.22), p = 0.04
Lumbar versus Hip end-range flexion ROM**, n = 4 -0.21 (-0.52 to 0.09), p = 0.17
Pelvic tilt angle in standing
†
, n = 3 0.24 (-0.03 to 0.50), p = 0.08
Speed/Acceleration
‡
,n=8 -1.24 (-1.58 to -0.90), p < 0.0001
Proprioception (re-position accuracy)
§
, n = 12 1.04 (0.64 to 1.45), p < 0.0001
*Positive numbers indicate larger lordosis for the LBP group, **negative numbers indicate reduced ROM for the LBP group, †positive numbers indicate larger
anterior tilt,
‡
negative numbers indicate reduced speed of movement for the LBP group,
§
positive numbers indicate greater error rate in re-positioning
(reduced proprioception).
Table 3 Differences between the LBP and NoLBP in within-group variability on each movement characteristic and
ratios of n-weighted mean coefficients of variation
Movement Characteristic
(number of comparisons)
LBP group
coefficient of variation
N NoLBP group
coefficient of variation
n Ratio of coefficients
of variation (95% CI)
Lordosis angle (8) 33.1% 818 34.6% 745 0.96 (0.83 to 1.10)
Flexion ROM* (18) 35.1% 913 26.8% 778 1.31 (1.13 to 1.51)
Extension ROM (12) 41.5% 485 47.2% 515 0.88 (0.76 to 1.01)
Lateral flexion ROM (9) 52.6% 751 40.1% 614 1.31 (1.17 to 1.48)
Rotation ROM* (10) 34.3% 827 28.7% 590 1.20 (1.02 to 1.40)
Lumbar vs hip (6) 51.2% 111 42.8% 74 1.2 (0.87 to 1.65)
Speed/acceleration* (8) 54.7% 602 42.6% 475 1.28 (1.13 to 1.46)
Proprioception (13) 53.9% 435 53.2% 229 1.01 (0.87 to 1.18)
*Statistically significant differences (95% CIs >1.0) are bolded.
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on whether an assessment of movements without reference
to pain provides evidence of dysfunction at an individual
patient level. The results neither endorse nor disqualify
the role of movement assessment for (i) determining the
relationship between movement and pain in individual
patients, or (ii) monitoring changes in movement charac-
teristics as a means of monitoring progress in individual
patients and as an indication of the likelihood of their im-
provement [87]. Key questions also remain, including (a)
are deficits such as reduced proprioception, reduced ROM
and speed of movement a result or a cause of LBP, and (b)
are these deficits present prior to the development of
LBP?
Strengths and limitations
The strengths of this systematic review are the compre-
hensive search, the breadth of the movement character-
istics included in the analysis, and that screening and
data extraction were independently performed by two
reviewers. In addition, the review only included studies
that assessed people with and without LBP using the
same within-study method, thereby removing method
differences as an explanation for observed within-study
differences.
The review also has limitations. We treated the data
for people with LBP as if they were measurements of a
homogenous group. It is possible that sub-grouping by
using the relationship of pain to movement may increase
the clinical utility of particular measurements. The find-
ings in this review do not inform clinicians about whether
changes in ROM, movement speed or proprioception will
produce better outcomes, or if changes in movement
characteristics precede the onset of LBP or predispose to
future recurrences. In addition, due to an absence of
translation resources, only articles published in English
were included and this may introduce a language, cultural
and/or publication bias. To maximize the number of in-
cluded studies, we did not place any restrictions on the
criteria used to define pain cases versus pain-free controls.
However, our broad inclusion criteria are likely to have
weakened, rather than strengthened differences seen be-
tween people with and without LBP, and in the included
studies, higher pain intensities had a weak correlation with
increased differences between the these groups.
Conclusion
This paper systematically summarised what is known
about differences in measurements of lumbo-pelvic move-
ment for people with and without back pain. It included
43 studies and synthesised information on six movement
characteristics: lordosis, ROM, lumbar versus hip contri-
bution, pelvic tilt, speed and proprioception. The results
show that compared to people without pain, on average,
people with LBP display (i) no difference in their lordosis
angle (8 studies), (ii) a reduction of lumbar ROM in all di-
rections of movement (26 studies), (iii) no difference in
lumbar versus hip ROM contribution to full flexion (4
studies), (iv) no difference in pelvic tilt angle in standing
(3 studies), (v) slower lumbar movement (7 studies), and
(vi) poorer proprioception on position-reposition accuracy
(15 studies). There is greater movement variability for
people with LBP for flexion, lateral flexion and rotation
ROM, and speed of movement, but this is not apparent
for other movement characteristics. So put simply, when
considered collectively, people with LBP have reduced
lumbar ROM, move more slowly and have reduced pro-
prioception compared with people without low back pain.
Additional files
Additional file 1: Search strategy medline.
Additional file 2: Quality assessment.
Additional file 3: Categories of included studies.
Additional file 4: Characteristics of included studies.
Additional file 5: Quality assessment.
Additional file 6: Summary of studies examining lumbar
proprioception.
Abbreviations
LBP: Low back pain; ROM: Range of motion; SMD: Standardised mean
difference; NoLBP: People without low back pain.
Competing interests
No funding was received for this systematic review. No benefits in any form
have been, or will be, received from a commercial party related directly or
indirectly to the subject of this paper. This paper does not contain information
about medical devices or drugs. The authors do not hold stocks or shares in
any company that might be directly or indirectly affected by this review. No
patents have been applied for or received due to the content of this review.
There are no non-financial competing interests associated with this review.
Authors’contributions
RL and JG contributed to data collection. RL and JG performed data inclusion and
extraction with JK providing arbitration when required. All authors were involved
in the design of the review, analysis and interpretation of data, drafting and
revision of the manuscript, and gave approval of the final manuscript.
Acknowledgements
None.
Author details
1
Department of Physiotherapy, Monash University, PO Box 527, Frankston,
VIC 3199, Australia.
2
Peak MSK Physiotherapy, Suite 4/544 Hampton St,
Hampton, VIC 3188, Australia.
3
Department of Sports Science and Clinical
Biomechanics, University of Southern Denmark, Odense 5230, Denmark.
4
Research Department, Spine Centre of Southern Denmark, Lillebaelt
Hospital, Institute of Regional Health Services Research, University of
Southern Denmark, Middelfart 5500, Denmark.
5
7 Kerry Rd, Warranwood,
Melbourne, VIC 3134, Australia.
Received: 13 May 2014 Accepted: 1 July 2014
Published: 10 July 2014
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doi:10.1186/1471-2474-15-229
Cite this article as: Laird et al.:Comparing lumbo-pelvic kinematics in
people with and without back pain: a systematic review and
meta-analysis. BMC Musculoskeletal Disorders 2014 15:229.
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