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R E S E A R C H A R T I C L E Open Access
The effect of different lumbar belt designs on the
lumbopelvic rhythm in healthy subjects
Christian Larivière
1,3*
, Jean-Maxime Caron
2,3
, Richard Preuss
2,3
and Hakim Mecheri
1,3
Abstract
Background: Research suggests that in some patients with low back pain, lumbar belts (LB) may derive secondary
prophylactic benefits. It remains to be determined, however, which patients are most likely to benefit from
prophylactic LB use, and which LB design is optimal for this purpose. The objective of this study was to determine
the effect of different lumbar belts designs on range of motion and lumbopelvic rhythm.
Methods: Healthy subjects (10 males; 10 females) performed five standing lumbar flexion/extension cycles, with
knees straight, during a control (no belt) and four lumbar belt experimental conditions (extensible, with and
without dorsal and ventral panels; non-extensible). Motion of the pelvis and lumbar spine was measured with 3D
angular inertial sensors.
Results: The results suggest that adding dorsal and ventral panels to an extensible LB produces the largest lumbar
spine restrictions among the four tested lumbar belt designs, which in turn also altered the lumbopelvic rhythm.
On a more exploratory basis, some sex differences were seen and the sex × experimental condition interaction just
failed to reach significance.
Conclusions: LB may provide some biomechanical benefit for patients with low back disorders, based on the
protection that may be provided against soft tissue creep-based injury mechanisms. More comprehensive
assessment of different LB designs, with additional psychological and neuromuscular measurement outcomes,
however, must first be conducted in order to produce sound recommendations for LB use. Future research should
also to take sex into account, with sufficient statistical power to clearly refute or confirm the observed trends.
Keywords: Lumbar support, Coordination, Kinematics
Background
While lumbar belts (LB) do not appear to reduce the risk
of a first episode of low back pain [1,2], some patients with
low back pain may derive secondary prophylactic benefits
from LB use [1]. It remains to be determined, however,
which patients are most likely to benefit from prophylactic
LB use, and which LB design is optimal for this purpose.
Psychological [3], neuromuscular and biomechanical
[4] mechanisms have all been proposed to explain the
clinical benefits of LB, but remain unproven. Psycho-
logical benefits are likely associated with the perceived
mechanical support derived from the LB [3], while any
neuromuscular likely involves mechanisms that influence
lumbar stability, such as lumbar proprioception, trunk
muscle feedforward and reflex activity [5-8]. The direct
biomechanical benefits of LB, on the other hand, are likely
related to the mechanical stiffness of the LB, leading to de-
creased lumbar range of motion (ROM) [3,4,9], reduced
stresses in the passive tissues of the posterior lumbar spine
[10,11] and potentially to reduced compressive loading of
the lumbar spine [12]. The direct biomechanical impact of
LB is the focus of the current study. Specifically, we aim
to assess the influence of LB stiffness on lumbar spine
ROM and on the coordination between the pelvis and the
lumbar spine during movement, hereafter called the lum-
bopelvic rhythm.
To the authors’knowledge, three previous studies have
assessed body segment kinematics during lifting, while
* Correspondence: lariviere.christian@irsst.qc.ca
1
Occupational Safety and Health Research Institute Robert-Sauvé (IRSST), 505,
boul. De Maisonneuve Ouest, Montreal, Quebec H3A 3C2, Canada
3
Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal
(CRIR), Montreal, Canada
Full list of author information is available at the end of the article
© 2014 Larivière 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.
Larivière et al. BMC Musculoskeletal Disorders 2014, 15:307
http://www.biomedcentral.com/1471-2474/15/307
wearing a LB [9,13,14]. One of these studies only ad-
dressed body position at peak compression force, and
thereforeprovideslittleinsightintotheeffectsofLBon
movement coordination [14]. The other two studies, how-
ever, provide evidence of altered inter-segmental coor-
dination compared to lifting without a LB, suggesting that
LB use changes the natural style of lifting [9,13]. Only
McGorry and Hsiang [13], however, treated the lum-
bar spine and pelvis as separate segments. Their results
showed similar ROM measures for two types of LB (elastic
and rigid), with a decrease in lumbar flexion compensated
for by an increase in pelvic flexion. No significant change
in the lumbopelvic rhythm, however, was found for any
of the lifting and lowering stages. Unfortunately, these
authors did not provide a detailed description of the LBs
used in the study, making the interpretation and applica-
tion of these findings difficult. Furthermore, the LB ten-
sion was volunteer-selected, which may have affected the
outcomes. Further study of the effect of different LB de-
signs on the lumbopelvic rhythm, therefore, is necessary
to enhance the knowledge in this field, and ultimately to
guide the prescription of LB by healthcare practitioners.
The objective of the current study was to determine the
effect of different LBs designs on the lumbopelvic rhythm
of healthy male and female subjects during a forward
bending task. Two broad categories of LBs were studied -
categorized as extensible (elastic) and non-extensible -
having first been identified as flexible enough to be used
at work. Furthermore, as many commercial LB also allow
the possibility of adding dorsal and/or ventral inserts,
which is purported to enhance lumbar stiffness, these
designs were also included. A standardized, maximal
trunk flexion/extension task (without lifting) was used
to reduce any variability in movement patterns associated
with lower and upper limb movements, with the goal of
better isolating the intrinsic effect of a LB on the lumbo-
pelvic rhythm. Sex effects were also investigated, as differ-
ences have been previously found between males and
females for both pelvic and lumbar ROM [15,16] and lum-
bopelvic rhythm [17] during trunk flexion/extension tasks.
Methods
Subjects
Twenty healthy subjects (10 men + 10 women), aged be-
tween 18 and 65 years, were recruited on a word of
mouth basis, with male and female subjects matched for
age (Table 1). Exclusion criteria were as follows: back
pain in the preceding month; having a body mass index
(BMI) greater than 31.5 kg/m
2
(women) or 33 kg/m
2
(men); prior surgery of the pelvis or spinal column;
scoliosis; systemic or degenerative disease; one positive
response to the Physical Activity Readiness Question-
naire [18]; history of neurological diseases or deficits not
related to back pain (e.g., stroke, peripheral neuropa-
thies, balance deficits); use of anticonvulsive, antide-
pressive and anxiolitic medication (use of antispasmodic,
anti-inflammatory and analgesic drugs for back pain were
accepted); pregnancy; claustrophobia; abnormal arterial
blood pressure (hypertension). All subjects were informed
about the experimental protocol and potential risks and
gave written consent prior to their participation. The eth-
ics committee of the Centre for Interdisciplinary Research
in Rehabilitation of Greater Montreal (CRIR) approved
the study and consent form.
Lumbar belts investigated
The two models of LB are illustrated in Figure 1, and
were chosen, in consultation with an orthotist, based on
functionality for use at work (flexible, comfortable), af-
fordability and durability. The first was an extensible LB
that allowed for insertion of dorsal and ventral panels
(model LumboLux from Hope Orthopedic). The second
was a non-extensible LB without panels (model 582
from MBrace). Both LBs had two layers of straps, se-
cured with Velcro material; the first layer allowing for
initial adjustment and placement of the LB, and the
Table 1 Characteristics of the male and female subjects
Males (n = 10) Females (n = 10) T-test
Mean (SD) Mean (SD) Pvalue
Age (yr) 26 (8) 27 (11) 0.551
Height (m) 1.80 (0.06) 1.68 (0.07) 0.007
Mass (kg) 80 (13) 65 (10) 0.024
BMI (kg/m
2
) 25 (3) 23 (3) 0.286
Spine length* 0.449 (0.034) 0.393 (0.021) 0.002
Extensible belt upper edge at …† T12 [T11-T12] T11 [T9-T12] /
N-extensible belt upper edge at …† T12 [T11-T12] T11 [T9-T12] /
Thoracic sensor upper edge at …† T9 [T8-T9] T8 [T7-T9] /
*:C7 spinous process height minus L5 spinous process height; †: spinous process touched by the upper edge of the belt or upper edge of the thoracic inertial
sensor, reported as mean [min-max].
Significant P values are identified in bold characters.
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second layer (elastic material for the extensible LB and
non-extensible nylon straps for the non-extensible LB)
allowing the final tension adjustment. The optional ven-
tral panel for the extensible LB was semi-rigid and cov-
ered with a Velcro material, allowing it to be anchored
with the first Velcro strap. The dorsal panel was a rigid
Kydex insert, with a hole in the middle to allow the
spine to flex without discomfort.
Both LBs are commercially available in seven lengths,
but have a standard height (front: 6 inches; back: 10
inches). The 6-inch front is typical of most “low-profile”
LBs on the market, and is purported to be less restricting
for trunk flexion. The use of these commercially-available
LBs, therefore, did not allow for standardization of LB
height based on the height of the individual subjects,
which may impact the findings of this study; in particular
the comparison between sexes, as women tend to be shor-
ter than men. Consequently, the highest vertebral spinous
process covered by the LB was recorded, and spine length,
as defined by the distance between the L5 and C7 pro-
cesses, was used as a covariate for sex comparisons (see
Statistical analyses section).
During testing, each LB was positioned over a T-shirt,
with the subject sitting, so that the lower edge of the LB
covered the antero-superior iliac spines, without touch-
ing the thighs. Before each experimental condition in-
volving a new LB, the tension of the LB was adjusted at
rest, with the subject standing upright. This step was
performed with the use of a FSR sensor (Force Sensing
Resistor; Interlink Electronics; model FSR400; see Figure 2)
fastened on the skin between the lateral aspect of the left
iliac crest and the 12
th
rib. During task performance, sub-
jects reported that the presence of the sensor was imper-
ceptible. Using this feedback system, the subject adjusted
thetensionintheLBtoreachapressureof70mmHgor
9.
3 KPa [19], allowing for a 5% error. For some smaller
subjects (mostly women), however, the target pressure
of 9.
3 KPa could not be reached. In these cases, the
belt pressure was applied at a target between 8.0 and
8.8 KPa ± 5%, and a matching belt pressure was used
with the subsequent male subject(s).
Task and experimental conditions
From a standing position, keeping the knees as straight
as possible during the task, subjects were asked to flex
the trunk forward as far as possible without contracting
the abdominals, and return to the upright position. For
each of the five experimental conditions (detailed below),
five consecutive cycles of the movement were performed,
following the pace of a metronome (4 s to flex, 4 s to
relax, 4 s to extend, 4 s to relax). The head was fully flexed
through the whole task to prevent movement of the cer-
vical vertebrae. Subjects performed the task during five
randomly-ordered experimental conditions: (1) the con-
trol condition without LB (Control), (2) extensible LB
without panels (ExtLB), (3) extensible LB with dorsal
panel (ExtLB-D), (4) extensible LB with dorsal and ven-
tral panels (ExtLB-DV), (5) non-extensible LB (NExtLB).
These experimental conditions were designed to progres-
sively increase the stiffness provided by LBs.
AB
Figure 1 Illustration of the tested lumbar belts. On the left (A), the extensible lumbar belt with dorsal (upper left) and ventral (upper right)
panels. On the right (B), the non-extensible lumbar belt. The two nylon straps make this belt non-extensible.
Figure 2 The FSR pressure sensor allowing to standardize the
tension of the lumbar belts. To homogenize the pressure applied
on the sensor, the 4.0 × 4.0 cm sensor was supported with a
semi-rigid plastic sheet and covered with a Styrofoam layer (total
thickness of the three layers: 2 mm).
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Measurement techniques and procedures
The angular kinematics of the pelvis and lumbar spine
was recorded (sampling rate: 100 Hz) with a 3D-motion
system comprising inertial sensors (X-Sens Motion Tech-
nologies, Enschede, The Netherlands). A first sensor fol-
lowed the motion of the sacrum while a second sensor
was positioned on the thoracic vertebrae not covered by
the LBs, as illustrated in Figure 3. The highest spinous
process covered by the thoracic sensor (generally covers
two spinous processes) was identified and recorded.
Data processing and analyses
All angular position signals recorded in the sagittal plane
were first filtered using a fourth-order, zero-lag Butter-
worth filter with 3-Hz cut-off frequency. The five flexion/
extension cycles were then separated into individual cycles
and phases (flexion, extension), using a threshold of 5% of
the thoracic sensor peak angular velocity.
The angular position of the sensor at the sacrum/
pelvis (Ang
PE
)andonthethorax(Ang
TH
)wereused
to calculate the lumbar spine angle (Ang
LU
=Ang
TH
-
Ang
PE
). Ang
PE
and Ang
LU
values at the beginning and
end of trunk flexion were used to compute the range
of motion (ROM) of the pelvis (ROM
PE
)andlumbar
spine (ROM
LU
), respectively. ROM
PE
and ROM
LU
were
summed to calculate the total trunk ROM (ROM
Tot
). The
relative contribution of the lumbar spine to the total trunk
ROM was then computed as follows:
%ROMLU ¼ROMLU
ROMTot
100
Statistical analyses of these data showed that the
%ROM
LU
captures the same information as the cor-
responding variable computed for the pelvis (%ROM
PE
)
or as the popular lumbopelvic ratio (ROM
LU
/ROM
PE
).
The lumbopelvic ratio, however, may produce outliers
when the denominator is close to zero. To provide clear
and concise results, therefore, only the analysis of the
%ROM
LU
is reported as a measure of relative segmental
motion.
Each phase of the motion task (flexion, extension) was
further separated into four intervals (0-25; 25-50; 50-75;
75-100% of ROM
Tot
), and the intervals for the extension
phase were inverted to allow for direct comparison with
the flexion phases. Intervals 1 and 4, therefore, corres-
pond to the upright and flexed positions respectively, for
both phases.
The coordination between the pelvis and lumbar spine
was quantified using a relative phase angle (RPA) ana-
lysis, in which the phase difference between the lumbar
and pelvic segments is determined based on the velocity
profiles of each segment as a function of its relative an-
gular position [20,21]. New standards to compute these
analyses were followed [22]. A difference between the
two segments of 0° indicates that the lumbar spine and
pelvis segments are moving perfectly in phase, positive
values indicate that the lumbar spine is leading the pelvis
in the phase space, negative values indicate that the lum-
bar spine is lagging behind the pelvis, and 180° indicates
that the segments are perfectly out of phase. Three vari-
ables were extracted from the relative phase angle curve
for both the flexion and extension phases of the cycle;
RPA
Mean
,RPA
Std
and RPA
Max
, which are the mean, the
AB C
Figure 3 Procedure used to allow the monitoring of the pelvis and lumbar spine without interference from the lumbar belts. The upper
inertial sensor, positioned on the thoracic spine, was secured on a piece of foam (A), allowing the wire not to interfere with the LB. The lower
inertial sensor was glued on an angulated piece of plastic (A), which was inserted in a hole just below the short pants elastic band (B) and
secured on the sacrum by three means (glue, Hypafix tape, 3-cm wide elastic band surrounding the sacrum and antero-superior iliac spines).
The elastic band was deemed required during the control (no LB) condition and could not provide any lumbar support. The LBs were simply
overlying the 3-cm elastic band, the plastic plate and the sacrum (C), which prevented any discomfort during the trials. Consent to publish was
given by the model in this image.
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standard deviation (variability of the coordination) and
the extreme values (maximum when positive and mini-
mum when negative) of the relative phase angle curve,
respectively.
Statistical analyses
All statistical analyses were done with NCSS software
(version 6.0 for Windows), using a significance level
(alpha) of 0.05. Because some variables showed abnor-
mal distributions, we elected to systematically transform
all variables [23] to normalize their distributions, as ve-
rified with the Wilk-Shapiro test, thus allowing the use
of parametric statistical analyses. Note, however, that
values reported in tables and figures are the untrans-
formed values.
Preliminary analyses (repeated measures ANOVAs) re-
vealed that the first movement cycle was significantly
different than some of the remaining cycles (cycle 2 and/
or 3 and/or 4 and/or 5) for many kinematic variables
and pressure measures, possibly because of learning or
some repositioning of the sensors or LBs during the first
cycle. In other words, cycles 2, 3, 4 and 5 were always
non-significantly different. Consequently, for each vari-
able, the average value of the last four cycles was retained
for further analyses.
Two-way ANOVAs (2 SEX × 5 CONDITION) for re-
peated measures on the CONDITION factor (1 control
and 4 LB conditions) were carried out on all dependent
variables except %ROM
LU
, for which a 3-way ANOVA (2
SEX × 5 CONDITION × 4 INTERVAL) for repeated
measures on the CONDITION and INTERVAL (0-25;
25-50; 50-75; 75-100% of ROM
Tot
) factors was used. Sep-
arate analyses were performed for the flexion and exten-
sion phases. Post-hoc pairwise comparisons were carried
out with the Tukey-Kramer test.
To determine whether sex comparisons could be con-
founded by the number of vertebrae covered by the LBs
(for variables specific to the lumbar spine), ANCOVAs
were carried out for each condition (for all dependent
variables) and interval (for %ROM
LU
only), using spine
length as a covariate.
Results
Assessment of potential confounding variables
The area covered by the LB in males and females is de-
scribed in Table 1, confirming that LBs covered more
vertebrae in women, which in turn forced the position-
ing of the upper inertial sensor on higher thoracic verte-
brae. However, on average, the difference was only one
vertebra. These results are explained by the significantly
smaller spine length of females (39.3 ± 2.1 cm) relative
to males (44.9 ± 3.4 cm).
The pressure generated by the belt during the upright
and flexed trunk postures, as well as during the entire
task (last four cycles), did not show SEX main effects,
although a SEX × CONDITION interaction reached signi-
ficance in the upright position (Table 2). Women showed
a decrease of pressure across the belt conditions (from C2
to C5) whereas the opposite was seen in males, although
these changes were not significantly different (1-way
ANOVAs for each sex separately). However, this led to a
significant SEX effect during the NExtLB condition (Δ=
0.95 KPa; P= 0.027), as further disclosed with separate T-
tests. This might be explained by the fact that even though
we paired the belt pressures of some men with those of
smaller women, the difference in belt pressure between
sexes increased as the stiffness of the belt increased since
the belt could adapt less to the body surface. A stiffer LB
would prevent the belt from wrapping tightly around the
abdomen of smaller women relatively to male subjects,
which were bigger in general.
Although no significant difference was seen in the
upright position, the NExtLB condition showed a sig-
nificantly lower pressure (8.36 KPa) than other belt
conditions (8.76 to 8.78 KPa) in the flexed position
(Table 2). This may be explained by a pouch created at
the position of the pressure sensor, which likely corre-
sponded to the space between the straps of the NExtLB.
Table 2 Lumbar belt pressure values (KPa) corresponding to different trunk postures and statistical analyses
Trunk posture Sex Mean (SD) values for each experimental condition ANOVA (P values) Post hoc (C)
ExtLB (C2) ExtLB-D (C3) ExtLB-DV (C4) NExtLB (C5) Sex (S) Condition (C) S × C
Upright ♂8.85 (0.78) 8.91 (0.77) 9.09 (0.64) 9.29 (0.58) 0.172 0.993 0.008 /
♀8.86 (0.62) 8.74 (0.79) 8.62 (0.70) 8.34 (1.09)
Flexed ♂8.93 (0.55) 9.00 (0.40) 8.93 (0.46) 8.53 (0.55) 0.188 < 0.001 0.976 C2,C3,C4 > C5
♀8.60 (0.61) 8.55 (0.78) 8.57 (0.60) 8.19 (0.80)
Mean across ♂8.89 (0.67) 8.96 (0.61) 9.01 (0.56) 8.91 (0.68) 0.160 0.168 0.140 /
Entire task ♀8.73 (0.62) 8.65 (0.79) 8.60 (0.65) 8.27 (0.96)
♂: males; ♀: females; LB: lumbar belt; ExtLB: extensible LB without panels; ExtLB-D: extensible LB with the dorsal panel; ExtLB-DV: extensible LB with dorsal and
ventral panels; NExtLB: non-extensible LB. Significant P values are identified in bold characters.
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However, although statistically significant, this differ-
ence was small (4.6%) and considered negligible.
Effect of experimental conditions (LB designs) on ROM
The SEX × CONDITION interactions were not statisti-
cally significant (Table 3), although a trend (P= 0.071)
was observed for ROM
LU
(Figure 4). SEX was significant
only for ROM
PE
, with females showing a 13° higher
ROM than males (52° > 39°). For ROM
LU
, accounting for
sex differences in spine length with the use of ANCO-
VAs (for each experimental condition) did not change
the conclusions (no SEX effect; spine length covariate
was not significant).
Wearing a LB did not influence ROM
PE
but affected
ROM
LU
(Table 3). More precisely, wearing any LB de-
creased ROM
LU
relative to the control condition by an
amount ranging from 9 to 15° (Figure 4). Considering
that ROM
PE
was not affected, ROM
Tot
, represented by
the sensor positioned at the thoracic level, also signifi-
cantly decreased (ANOVA P< 0.001; Post hoc compari-
sons: C1 > C3,C4,C5 and C2 > C5) by an amount ranging
from 6 to 13°. Also, the ExtLB-DV condition limited
more ROM
LU
than the ExtLB condition.
Effect of experimental conditions (LB designs) on the
lumbopelvic rhythm variables
The %ROM
LU
variable, computed across phases (flexion,
extension) and intervals, revealed that all main effects
(SEX, CONDITION, INTERVAL) and some interactions
reached statistical significance (Table 4). The ANCOVAs
carried out to account for spine length differences be-
tween sexes did not uncover any difference relative to
sex effects for this variable. SEX × CONDITION interac-
tions just failed to reach statistical significance (0.05 <
P< 0.10) but a SEX × INTERVAL (during extension) and
CONDITION × INTERVAL interaction reached signifi-
cance. Details of these findings are illustrated in Figure 5.
Table 5 provides additional statistical explanations of the
CONDITION × INTERVAL interactions based on separ-
ate one-way ANOVAs for repeated measures between
conditions for each interval and between intervals for
each condition. For space constraints, these results are
described and immediately interpreted in details in the
discussion.
The relative phase angle variables showed neither sta-
tistically significant SEX × CONDITION interactions,
nor sex differences (Table 6), and the ANCOVAs carried
out to account for spine length differences between sexes
did not make any difference relative to sex effects on these
variables. The CONDITION factor was significant for the
three RPA variables (RPA
Max
,RPA
Mean
and RPA
Std
)and
the two phases (flexion and extension), as further illus-
trated in Figure 6. More specifically, during the flexion
phase, the three RPA variables were significantly higher
during the control condition than all the LB conditions.
RPA
Mean
showed further differences between the different
LB designs, with the ExtLB-DV condition showing lower
values than the ExtLB and NExt-LB conditions. During
the extension phase, the three RPA variables were signifi-
cantly higher during the ExtLB-DV condition than the
control, the ExtLB and NExt-LB conditions. Additional
differences involved the ExtLB-D condition, showing
higher RPA
Mean
values than the control and NExt-LB con-
ditions, and showing lower RPA
Std
values than the control,
ExtLB and NExt-LB conditions.
Discussion
The findings of this study provide direct evidence of the
biomechanical effects of LB use during trunk flexion/
extension. Wearing a LB significantly reduced lumbar
ROM while pelvis ROM remained unchanged. An effect
of LB design was also found, with lumbar ROM being
more greatly reduced by theExtLB-DVthanbythe
ExtLB design. LB use also significantly changed the
lumbopelvic rhythm, as revealed by different coordin-
ation variables.
On a more exploratory basis, sex differences were also
seen. Males showed less pelvic ROM and, in general,
more contribution to overall trunk ROM from the lum-
bar spine (%ROM
LU
). SEX × CONDITION interactions,
however, did not reach statistical significance, although
some trends (0.05 < P< 0.10) were observed. Further-
more, only a single interaction effect was found between
sex and other independent variables. Consequently, for
clarity, the effect of experimental conditions and of sex
will be discussed separately.
Effect of experimental conditions (LB designs) on ROM
The first finding of note was that all LB designs signifi-
cantly reduced lumbar ROM relative to the control
condition, while pelvis ROM remained unchanged. This
emphasizes the specific effect of LB use on lumbar
ROM, and is likely explained by an increase in lumbar
stiffness [24].
Previous studies have also shown a reduced lumbar ROM
with LB use [3,4,9]. This, however, was often accompanied
Table 3 Statistical results (Pvalues*) corresponding to
the effect of sex and experimental conditions on range of
motion (ROM) variables during the flexion phase
Variable ANOVA (P values) Post hoc (C)
Sex (S) Condition (C) S × C
ROM
PE
0.049 0.332 0.790 /
ROM
LU
0.122 < 0.001 0.071 C1 > C2,C3,C4,C5; C2 > C4
LB: lumbar belt; C1 (control): no LB; C2 (ExtLB): extensible LB without panels;
C3 (ExtLB-D): extensible LB with the dorsal panel; C4 (ExtLB-DV): extensible LB
with dorsal and ventral panels; C5 (NExtLB): non-extensible LB. *Significant
Pvalues are identified in bold characters, while trends (0.05 < P< 0.10) are
identified in italics.
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by an enhanced ROM at peripheral joints such as at the
knees and hip, or in the thoracic spine [3,9]. The current
study, however, was specifically designed to isolate the in-
trinsiceffectofaLBonthelumbopelvicrhythm.Pain-free
subjects were used, and, unlike freestyle lifting, the selected
task was limited to trunk flexion/extension. Under these
strict conditions, no effect of LB use was found on pelvis
ROM, which suggests that the direct mechanical effect of
LBs is limited to the lumbar spine (the immediate effect on
thoracic spine ROM, however, was not assessed). Further-
more, the purpose of the task being to achieve maximal
trunk flexion, the possibility that a part of the reduced lum-
bar ROM was explained by sensory feedback serving as a
reminder for good postural hygiene was excluded.
The lumbar ROM was also more affected by the ExtLB-
DV than by the ExtLB design, the former showing the
largest effect (15°) relative to the control condition. This
suggests that adding ventral and dorsal panels further
stiffens the lumbar spine, as proposed by LB manufac-
turers. One previous study has directly evaluated the ef-
fects of different LB designs on lumbar stiffness, using a
sudden trunk perturbation task [19]. The non-extensible
LB used in this previous study increased trunk stiffness by
14% relative to an extensible LB. Adding a ventral panel to
the non-extensible LB, however, produced no further mea-
sureable increase in stiffness (the effect of panels with the
extensible LB was not assessed). Assessing the findings of
this previous study, along with the different effects of LB
design on different task and outcome measures (ROM
LU
,
%ROM
LU,
relative phase angle variables) in the current
study, suggests the need to consider both mechanical and
neuromuscular outcome measures to better delineate the
pros and cons of different LB designs.
From a clinical perspective, the decrease in lumbar
ROM that was observed with all LB designs in the cur-
rent study may have a positive impact on mechanisms of
injury linked with the progressive creep of the lumbar
spine posterior passive-tissues. Induced tissue creep, via
sustained or repetitive lumbar flexion, is known to re-
duce intrinsic lumbar stiffness, impair back muscle re-
flexes [25-28] and disturb trunk postural control [29].
Tissue creep may also trigger inflammatory processes
and enhance muscle spasm [30]. Cumulative exposure to
repetitive or sustained trunk flexion, which is common
in many occupations (e.g. manual materials handlers,
roofers, bricklayers, gardeners, movers, etc.), may there-
fore predispose workers to low back injury and pain. A
non-negligible reduction of lumbar flexion, by 9 to 15°
with the use of LB may therefore reduce these risks by
decreasing tissue creep. This might be particularly help-
ful when back muscle fatigue develops during repetitive
activities, knowing that lumbar flexion progressively
arises in these circumstances [31]. This may also help
patients with lumbar posterior passive-tissue injuries to
return to work more rapidly without exacerbating their
pain or compromising their safety.
Figure 4 Range of motion of the pelvis (ROM
PE
) and lumbar spine (ROM
LU
) in males and females for each lumbar belt (LB)
experimental condition. C1 (control): no LB; C2 (ExtLB): extensible LB without panels; C3 (ExtLB-D): extensible LB with the dorsal panel; C4
(ExtLB-DV): extensible LB with dorsal and ventral panels; C5 (NExtLB): non-extensible LB. *Statistically significant differences between experimental
conditions are identified at the top of each graph.
Table 4 Statistical results (Pvalues*) corresponding to the effect of sex, experimental conditions and intervals on the
relative contribution of the lumbar spine to the total trunk range of motion (%ROM
LU
)
Phase ANOVA (Pvalues)
Sex (S) Condition (C) Interval (I) S × C S × I C × I S × C × I
Flexion 0.024 <0.001 <0.001 0.059 0.514 <0.001 0.444
Extension 0.041 <0.001 <0.001 0.086 0.032 <0.001 0.935
*Significant Pvalues are identified in bold characters, while trends (0.05 < P< 0.10) are identified in italics.
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Effect of experimental conditions (LB designs) on the
lumbopelvic rhythm variables
The findings of the current study indicate that LB use
may affect the coordination of movement between the
lumbar spine and pelvis. As might be expected from the
reduced lumbar spine ROM with LB use, the contri-
bution of the lumbar spine to the overall trunk ROM
(%ROM
LU
) was also reduced for all LB conditions, in
both the flexion and extension phases (Figure 5 -upper
plots). No difference, however, was noted between any
of the LB conditions. This effect is illustrated in the
interval-specific results (Figure 5 –middle and lower
plots). As in previous studies [32-35], the lumbar spine
contributed progressively less to overall trunk flexion
Figure 5 The relative contribution of the lumbar spine to the total trunk ROM (%ROM
LU
variable), illustrated in different plots to
understand the SEX × CONDITION (upper plots), SEX × INTERVAL (middle plots) and CONDITION × INTERVAL (lower plots) interactions.
Pvalues reported at the top of each plot correspond to the shown interaction. Left and right plots are for the flexion and extension phases,
respectively. Please keep in mind that the extension interval values were inverted to allow comparisons with the flexion phase intervals.
Experimental conditions (upper plots) or intervals (middle plot) that were different (P< 0.05) are identified with different letters (here A, B and
sometimes C) at the bottom of the corresponding graphs. When the interaction was significant, asterisks (*) were positioned to indicate where
SEX differences for a specific interval (right middle plot) or CONDITION differences for a specific interval (lower plots) were significant according
to post hoc analyses. C1 (control): no LB; C2 (ExtLB): extensible LB without panels; C3 (ExtLB-D): extensible LB with dorsal panel; C4 (ExtLB-DV):
extensible LB with dorsal and ventral panels; C5 (NExtLB): non-extensible LB. Standard deviations were not shown for clarity.
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(%ROM
LU
) as trunk flexion increased, with the differ-
ence becoming significant in the later intervals for both
the flexion (left middle plot) and extension (right middle
plot) movements. During the flexion movement, how-
ever, the progressive decrease of %ROM
LU
across inter-
vals was less pronounced with all LB designs conditions
relative to the control condition (Figure 5 –left lower
plot). A similar, although less evident effect also appears
during the extension movement (Figure 5 –right lower
plot). In other words, the reduction of the lumbar spine’s
contribution to overall trunk motion, as a result of LB
use, is more pronounced when standing than when the
trunk is fully flexed (Figure 5; Table 5). This more in-
depth analysis also revealed some differences between
specific LB designs in the more upright intervals of
motion (1
st
and 2
nd
interval during flexion; 1
st
interval
during extension). Here, the ExtLB-DV design produced
the greatest reduction in relative lumbar ROM when
compared to one or more of the remaining LB designs.
Once again, this is likely reflective of the additional stiff-
ness provided by the dorsal and ventral panels in the
ExtLB-DV design, leading to an altered lumbopelvic
rhythm in addition to a reduction in lumbar ROM, as
previously discussed.
The RPA variables (RPA
Max
,RPA
Mean
and RPA
Std
)were
all sensitive to the CONDITION factor during both fle-
xion and extension. RPA
Max
and RPA
Mean
values indicated
that the lumbar spine was leading the pelvis during flexion
(positive values) whereas the opposite was observed dur-
ing extension (negative values). However, all LB designs
reduced the leading of the lumbar spine over the pelvis
during flexion, which was in line with %ROM
LU
results
(Figure 5 –left lower plot). Moreover, RPA
Mean
results
showed that the ExtLB-DV produced the largest effect
in this respect, leading to significant differences with
the ExtLB and NExt-LB conditions. Likewise, the largest
Table 5 Statistical results (Pvalues*) corresponding to the post-hoc comparisons required to explain the CONDITION ×
INTERVAL significant interactions obtain for the %ROM
LU
variable
Flexion phase Extension phase
ANOVA Post-hoc comparisons ANOVA Post-hoc comparisons
P value (Tuckey-Kramer) P value (Tuckey-Kramer)
Interval* Between conditions Between conditions
1<0.001 1 > all; 2 > 3,4; 5 > 4 <0.001 1,5 > 3,4; 2 > 4
2<0.001 1 > all; 2,3,5 > 4 0.011 1>4
30.009 1 > 2,4,5 0.004 1 > 2,4,5
40.084 / 0.135 /
Condition†Between intervals Between intervals
1<0.001 1,2 > 3 > 4 <0.001 1,2 > 3 > 4
2<0.001 1 > 3,4; 2 > 4 <0.001 1,2 > 3 > 4
3<0.001 1,2,3 > 4 <0.001 1,2 > 3 > 4
40.027 1>4 <0.001 1,2 > 3 > 4
5<0.001 1 > 3,4; 2 > 4 <0.001 1>2>3>4
*In the first part of the table, a one-way ANOVA for repeated measures on the CONDITION factor was carried out for each interval separately. †A one-way ANOVA
for repeated measures on the INTERVAL factor was carried out for each condition separately. *Significant Pvalues are identified in bold characters, while trends
(0.05 < P< 0.10) are identified in italics.
Table 6 Statistical results (Pvalues*) corresponding to the effect of sex and experimental conditions on relative phase
angle variables
Phase angle Phase ANOVA (P values) Post hoc (C)
Variable Sex (S) Condition (C) S × C
RPA
Max
Flexion 0.592 <0.001 0.913 C1 > C2,C3,C4,C5
Extension 0.080 <0.001 0.445 C4 > C1,C2,C5
RPA
Mean
Flexion 0.546 <0.001 0.921 C1 > C2,C3,C4,C5 C4 < C2,C5
Extension 0.114 <0.001 0.599 C4 > C1,C2,C5 C3 > C1,C5
RPA
Std
Flexion 0.927 <0.001 0.871 C1 > C2,C3,C4,C5
Extension 0.064 <0.001 0.456 C1,C2,C5 > C3,C4
LB: lumbar belt; C1 (control): no LB; C2 (ExtLB): extensible LB without panels; C3 (ExtLB-D): extensible LB with dorsal panel; C4 (ExtLB-DV): extensible LB with dorsal
and ventral panels; C5 (NExtLB): non-extensible LB. *Significant Pvalues are identified in bold characters, while trends (0.05 < P< 0.10) are identified in italics.
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effects were observed for the ExtLB-DV condition (for
RPA
Max
and RPA
Mean
variables) during the extension
phase, but in the opposite direction (pelvis leading the
lumbar spine to a lesser degree relative to the control,
ExtLB and NExt-LB conditions). This was also observed
for the ExtLB-D condition, but to a lesser extent (RPA
Mean
variable only; relative to the control and NExt-LB con-
ditions). Overall, these findings further confirm that all
of the investigated LB designs altered the lumbopelvic
rhythm, and that this effect was enhanced with the use of
the dorsal panel, although the clinical significance of these
findings remains to be determined. These findings are
likely directly related to the mechanical stiffness provided
by the LB, as inter-segmental coordination is inextricably
linked to the control of segmental stiffness [36]. However,
the use of the ventral panel, in addition to the dorsal
panel, did not make a further difference.
All LB designs led to a reduction in the variability of
the relative phase angle (RPA
Std
)between the lumbar
spine and pelvis during trunk flexion, with a similar ef-
fect observed for the ExtLB-D and ExtLB-DV designs
during trunk extension. While an external support may
reduce the risk of injury due to a temporary loss of ac-
tive segmental control (due to muscle fatigue, loss of
concentration, etc.), it may also allow for less room for
variability in movement patterns by the central nervous
system. According to a recent hypothesis [37,38], such a
reduced variability may be detrimental for musculoske-
letal health, particularly when repetitive work activities
are performed, as it will lead to repetitive loading of the
same anatomical structures, and potentially to mechani-
cal tissue fatigue. Reduced motor variability, for example,
has been observed in subjects with chronic pain [39], and
may be emblematic of a pre-existing motor dysfunction or
of an inappropriate long-term compensation following an
acute injury [40].
Effect of sex
While differences between the sexes were not the pri-
mary focus of this study, some effects of sex were ob-
served that may be important in future work. Males
showed less pelvic ROM, which concurs with previous
findings [15,17]. Unlike previous studies [15,16], how-
ever, no difference was found in our data between men
and women for lumbar spine ROM.
Fitting with the findings above, the male participants
in our study showed more contribution from the lumbar
spine (%ROM
LU
) during trunk extension, particularly in
the flexed trunk posture. This is in line with the findings
of Nelson-Wong et al. [17], who showed a higher lum-
bar/hip ratio in males during extension from trunk
flexion. While our analysis suggests that spine length
Figure 6 Relative phase angle variables, all showing statistically significant differences between experimental conditions. C1 (control):
no LB; C2 (ExtLB): extensible LB without panels; C3 (ExtLB-D): extensible LB with dorsal panel; C4 (ExtLB-DV): extensible LB with dorsal and ventral
panels; C5 (NExtLB): non-extensible LB. *Experimental conditions that were different (P< 0.05) are identified at the top of each graph.
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differences did not drive these sex effects, certain SEX ×
CONDITION interactions did near statistical signifi-
cance (0.05 < P< 0.10) for ROM
LU
and %ROM
LU
(see
Figure 5 –upper plots) variables. This suggests that fu-
ture studies should account for sex, as these differences
may become more apparent in studies conducted with
larger sample sizes.
Perspectives
Although current evidence suggests that LB use does
not reduce the risk of a first episode of low back pain
[1,2], there may be a role for LBs for secondary and ter-
tiary prevention, as suggested by a systematic review
showing more controversial findings for patients with
low back pain [1] and the positive clinical findings ob-
served in the more recent randomized clinical trials
(RCTs) [41,42]. Interestingly, these RCTs were of longer
duration (>3 months). More research is needed to deter-
mine which workers with low back pain will benefit
more from this type of conservative intervention.
The results of the present study show that LB use, for
all designs tested, leads to a reduction in lumbar ROM.
This suggests that LB may be a good short or long-term
solution for patients with low back disorders, based on
the protection that may be provided against soft tissue
creep-based injury mechanisms [30]. Our results also
suggest that adding dorsal and ventral panels to an ex-
tensible LB produces the largest restrictions to lumbar
spine motion, among the four tested LB designs and the
largest alterations in the relative amplitude (%ROM
LU
)
and RPA (RPA
Max
and RPA
Mean
) measures of the lumbo-
pelvic rhythm. LB use, however, also led to a reduction
in the variability of segmental coordination patterns
(RPA
Std
). This may be viewed as a negative effect, in
light of current hypotheses related to the protective ef-
fects of motor variability against tissue fatigue and over-
use injury, and suggests that LB are a poor long term
solution for patients. It is thus difficult to give clear rec-
ommendations for LB use, and even trickier to propose
a specific LB design, based on the findings of this study.
A more comprehensive assessment of different LB de-
signs, with the use of different neuromuscular measure-
ment outcomes, must still be conducted, however, to
produce more individualized recommendations for LB
use. Longitudinal studies must also be conducted to de-
termine any long-term effects of LB use, taking into ac-
count any possible central nervous system adaptations,
and their effect on neuromuscular [43,44], psychological
(e.g. fears of pain/movement; not tested so far) and clin-
ical [1,41,42] outcomes.
The identification of patients that benefit more from
the use of LBs during clinical trials would demonstrate
that the net clinical benefits (pain, disability) of this sim-
ple intervention might outweigh the hypothesized but
not yet supported detrimental effects feared by some cli-
nical practitioners (false sense of security, psychological
dependence, maladaptative neuromuscular adaptations,
muscle atrophy and weakness). In the interim, the cau-
tious practitioner might prescribe a LB on working days
on which the patient had, or expected that they might
develop, low back pain [42]. This is in line with the rec-
ommendation of not using a LB over several consecutive
days or weeks [45]. Such a prescription might also be ac-
companied with clear messages about the importance of
trunk muscle support, the beneficial effect of physical/
work activity for the low back, and as such that activities
involving the low back must be progressively resumed as
soon as possible when symptoms decrease, and espe-
cially when the LB is withdrawn. Key messages provided
in the “Backbook”leaflet [46] would be recommended in
this perspective.
Strengths and limitations of the study
This study comprises several strengths. Firstly, great care
was taken to minimize any potential interference be-
tween the LBs and the kinematic sensors and to control
for LB pressure. The only potential confounding vari-
able, which was related to the relative height of the LBs,
was statistically accounted for to make valid sex compar-
isons. Secondly, a comprehensive study of the lumbopel-
vic rhythm was provided with the use of complementary
kinematic analyses, as discussed above. Third, more than
two LB designs were contrasted. Finally, we used a stan-
dardized task that allowed us to isolate the intrinsic ef-
fect of a LB on the lumbopelvic rhythm.
Limitations must also be acknowledged. These results
cannot be generalized to people with back pain. Further-
more, our analysis did not account for any effect on the
lumbothoracic rhythm. Finally, this exploratory study of
the possible effect of sex was likely underpowered, and
as such we encourage further testing of these findings
with a larger sample size.
Conclusions
LB may provide some biomechanical benefit for patients
with low back disorders, based on the protection that
may be provided against soft tissue creep-based injury
mechanisms. A more comprehensive assessment of dif-
ferent LB designs, with the use of different psychological
and neuromuscular measurement outcomes, however,
must be conducted to more fully understand the effects
of LB use, before more targeted recommendations for
LB use (or avoidance) can be produced for patient sub-
groups. Future research should also take sex into ac-
count, with sufficient statistical power to clearly refute
or confirm the observed trends.
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Abbreviations
Ang
LU
:Lumbar spine angle; Ang
PE
: Pelvis angle; Ang
TH
: Thorax angle;
ANCOVA: Analysis of covariance; ANOVA: Analysis of variance; BMI: Body
mass index; C1 to C5: Experimental conditions: control (C1), ExtLB (C2),
ExtLB-D (C3), ExtLB-DV (C4) et NExtLB (C5); ExtLB: Extensible LB without
panels; ExtLB-D: Extensible LB with dorsal panel; ExtLB-DV: Extensible LB with
dorsal and ventral panels; LB: Lumbar belt; NExtLB: Non-extensible LB;
RCT: Randomized clinical trial; ROM: Range of motion; ROM
PE
: ROM of the
pelvis; ROM
LU
: ROM of the lumbar spine; %ROM
LU
: Relative contribution of
the lumbar spine to ROM
Tot
;ROM
Tot
: Total trunk ROM; RPA: Relative phase
angle; RPA
Max
: Extreme values of the RPA curve; RPA
Mean
: Mean value of the
RPA curve; RPA
Std
: Standard deviation value of the RPA curve.
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
CL participated to the conception and design of the study, to the
supervision of the data acquisition, data processing and statistical analyses
and drafted the first version of the manuscript. JMC participated to the
conception and testing of the laboratory measurement protocol, recruited
the participants, collected all the data, carried out the statistical analyses and
revised the manuscript. RP participated to the conception and design of the
study and contributed heavily to the intellectual content of the manuscript.
HM performed the data processing, participated to the statistical analyses
and revised the manuscript. All authors have read and approved the final
manuscript.
Acknowledgements
This research project was funded by the Occupational Health and Safety
Research Institute Robert-Sauvé (IRSST) of Quebec (Canada). Jean-Maxime
Caron was supported (summer bursary) by the Quebec Rehabilitation
Research Network (REPAR). Special thanks go to Marilee Nugent, Daniel
Marineau and Michel Goyette for their technical assistance.
Author details
1
Occupational Safety and Health Research Institute Robert-Sauvé (IRSST), 505,
boul. De Maisonneuve Ouest, Montreal, Quebec H3A 3C2, Canada.
2
School of
Physiotherapy and Occupational Therapy, McGill University, Montreal,
Quebec J1K 2R1, Canada.
3
Centre for Interdisciplinary Research in
Rehabilitation of Greater Montreal (CRIR), Montreal, Canada.
Received: 14 February 2014 Accepted: 11 September 2014
Published: 19 September 2014
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doi:10.1186/1471-2474-15-307
Cite this article as: Larivière et al.:The effect of different lumbar belt
designs on the lumbopelvic rhythm in healthy subjects. BMC
Musculoskeletal Disorders 2014 15:307.
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