ArticleLiterature Review

The validity of O'Sullivan's classification system (CS) for a sub-group of NS-CLBP with motor control impairment (MCI): Overview of a series of studies and review of the literature

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Abstract

Chronic Low Back Pain (LBP) remains a common, recalcitrant and costly problem for the individual sufferer and for society. Effective treatments that reduce the social and economic burden have yet to be established for the majority of chronic LBP cases. Lack of evidence for specific interventions has been blamed on the heterogeneity of the chronic LBP population as well as a lack of a patient centred bio-psycho-social approach. This issue of heterogeneity has resulted in classification being considered the highest research priority in the area of chronic LBP. The potential for a 'wash-out effect' caused by the heterogeneity of the chronic LBP populations sampled for randomised controlled clinical trials (RCTs), has driven the need for classifying patients with nonspecific chronic LBP. A summary of a series of studies is outlined in this review paper. They represent a comprehensive investigation into the validity of O'Sullivan's proposed mechanism-based classification system (CS) for a sub-group of localized mechanically provoked nonspecific chronic LBP with motor control impairment (MCI). Further, the findings of these studies are discussed in relation to the relevant literature and the clinical implications arising are presented. Finally, the limitations of this research are outlined and recommendations for future research are made.

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... O'Sullivan's Classification System suggests that two main groups of subjects experiencing NSLBP can be identified; the first group demonstrates motor adaptations of the trunk in response to the pain produced by an alteration of the central nervous system and the second group demonstrates a peripheral pain and mechanical behavior of pain pattern in response to localized pain disorders (O'Sullivan 2005). This second group was classified as having a CI, because subjects have maladaptive patterns of movement of the lumbopelvic region (Astfalck et al. 2010;Dankaerts and O'Sullivan 2011). Dankaerts et al. (2006) reported an almost perfect agreement (kappa-coefficient 0.96; % of agreement 97%) between two expert clinicians using this classification system. ...
... Dankaerts et al. (2006) reported an almost perfect agreement (kappa-coefficient 0.96; % of agreement 97%) between two expert clinicians using this classification system. However, only two of five patterns have been validated as a clinical assessment tool for NSLBP (Dankaerts and O'Sullivan 2011;Dankaerts et al. 2009). These alterations are evaluated in the sagittal plane and not the axial plane and involved total body motion and not the effect of a specific hip motion. ...
... Participants who, according to the O'Sullivan classification, showed a movement pattern different from those currently validated (n = 3), were removed from the analysis. (Dankaerts and O'Sullivan 2011). Participants of the CI group showed Flexion Pattern (n = 5) or Active Extension Pattern (n = 4), according to O'Sullivan's Classification System (Dankaerts and O'Sullivan 2011;O'Sullivan 2005). ...
Article
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Purpose: To assess the presence of control impairment (CI) of the lumbopelvic region in the axial plane in men without low back pain (LBP) with CI in the sagittal plane. Methods: Twenty-four males, between 18 and 23 of age, BMI = normal, who did not report episodes of LBP in the 12 months prior to the study, were studied. Assessment of the sagittal control of the lumbopelvic region was performed during stand to sit. Nine participants demonstrated CI in sagittal plane and 15 did not. An active hip lateral rotation (HLR) test was performed, in which lumbopelvic rotation during HLR was assessed using a three-dimensional motion analysis system. Results: Patients with CI in sagittal plane had a greater percentage of their total lumbopelvic pelvic rotation at 60% of HLR range compared to those without CI (p < 0.05; d = 0.93). No significant differences in the total lumbopelvic and HLR range of motion were found between the groups. Conclusion: Men without LBP who experience CI of the lumbopelvic region in the sagittal plane also show CI in the axial plane. The control deficiencies were not related to the total range of lumbopelvic or HLR range of motion.
... Exercise prescriptions for CLBP have also been designed to address movement control impairments (MCI) (29,39). O'Sullivan and colleagues (29) developed a classification system to sub-categorise CLBP patients based on MCI. ...
... O'Sullivan and colleagues also proposed a sub-group classification of mechanical CLBP based on movement coordination (29,39). This classification system used tests of spinal flexion, extension, and rotation to sub-group patients into interventions to address their mechanical dysfunction (29,39). ...
... O'Sullivan and colleagues also proposed a sub-group classification of mechanical CLBP based on movement coordination (29,39). This classification system used tests of spinal flexion, extension, and rotation to sub-group patients into interventions to address their mechanical dysfunction (29,39). These assessments have been validated, and have been shown to be an effective system of sub-grouping CLBP patients (39). ...
Thesis
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Abstract Background Exercise is the first step recommendation for chronic low back pain (CLBP). However, the best approach for practitioners prescribing exercise to CLBP patients is unclear, and the efficacy of exercise in reducing pain-related disability is debated. Moreover, it is unknown if any particular mode of exercise or accompanying belief about physical activity holds any effect on manipulating CLBP patient beliefs associated with adherence or pain-related disability. Aim The aim of this thesis was to investigate how CLBP patient beliefs associated with adherence and pain-related disability are manipulated through physical activity. Therefore, this thesis aimed to observe: 1) if there are any differences between individualised and general exercise prescriptions at manipulating adherence and patient beliefs associated with adherence, 2) the influence of psychosocial variables associated with pain-related disability in a generalizable sample of people with CLBP, 3) if the belief physical activity is for CLBP manipulates psychosocial variables associated with pain-related disability, and 4) to provide preliminary results and methodological consideration to a larger longitudinal observational study. Results. The RCT showed no between-group difference for clinical outcomes or beliefs associated with adherence. Moreover, both groups showed increased patient beliefs after the initial session, despite the difference in structure and information provided. Adherence was high for both groups across the 8-week intervention to both practitioner-led and home-based sessions. These results suggest both individualised and general exercise programs are feasible for mild-to-moderate levels of CLBP. The cross-sectional observational study showed psychosocial variables associated with CLBP contribute to explaining the relationship between pain intensity and lower disability in a generalizable sample of people with CLBP. Higher functional self-efficacy and lower fear avoidance beliefs were reported as important variables in explaining the relationship between pain intensity and lower disability. Furthermore, engagement in physical activity for CLBP explained the association between higher functional self-efficacy and lower disability with reporting of worst pain in the last week. Engagement with physical activity for CLBP showed reduced levels of anxiety and small effects for functional self-efficacy, pain catastrophizing, and depression compared to participants who did not report the belief their physical activity was for their back pain. Methodological considerations for difference in reporting of current and previous pain intensity and the effect of physical activity for CLBP on functional self-efficacy, pain catastrophizing, anxiety, and depression were noted for the longitudinal observational study. These considerations will allow for this future research to explore if change in these variables explain causality in pain-related disability over time.
... Forward bending quality has been identified to predict those that would benefit from motor control exercises (MCEs) [8][9][10] . Aberrant movements have been identified in the midrange of motion, where muscle control is important for spinal stability 11) . ...
... Aberrant movements have been identified in the midrange of motion, where muscle control is important for spinal stability 11) . Sagittal plane movement and position sense have also been identified as valuable indicators in subgrouping patients into appropriate motor control subgroups 8) . Lumbar position and lordosis also have an impact on muscle activity, and repositioning errors may prevent patients from obtaining optimal spinal positions during movement 12) . ...
... MCE is based on motor-learning concepts to restore precise co-contraction pattern of deep abdominal and back muscles 17,18) . MCE a widely used physical therapy intervention to treat patients with LBP to improve motor control 8,18) . MCE typically involves three stages. ...
Article
[Purpose] To establish the test-retest reliability of an iPhone application and determine the immediate effect of motor control exercise (MCE) on lumbar position sense. [Participants and Methods] This study used a two-arm, randomized controlled trial design with a blinded assessor. Sixty healthy participants were randomized into the exercise or control group. The exercise group underwent 30-min MCE, whereas the control group rested for 15 min. Lumbar motion measured by two iPhones with goniometer application was used to determine the test-retest reliability. Absolute repositioning errors (pre- and post-test) from the control and exercise groups were used to determine the immediate effect of MCE on lumbar position sense. [Results] The test-retest reliability was 0.67–0.95. A significant interaction effect was found for Angle*Time, main effect of Angle, and main effect of Time. Post-hoc comparison showed a significant improvement in position sense at 45° and 60° in the exercise group. [Conclusion] The findings suggest that a mobile phone application has the ability to detect changes in lumbar position sense between sessions that exceed measurement error following MCE. One session of specific MCE can improve lumbar position sense at high lumbar flexion.
... The classification of MCI is based on the observation of aberrant movements accompanied by postural pain (O'Sullivan, 2005). A further sub-classification of MCI identifies the specific movement direction in which control is reduced (Dankaerts et al., 2006;Dankaerts and O'Sullivan, 2011). The subclassification categories are flexion, active extension, passive extension, lateral shift or multidirectional MCI (O'Sullivan, 2005). ...
... Age had to be 18e75 years. Eligible patients also had to present with: predefined MCI complaints (pain provocation in static positions) (Dankaerts and O'Sullivan, 2011), together with a score of two or more positive results out of the six MCI tests (Luomajoki et al., 2007). Disability levels had to be at least five points on the Roland Morris Disability Questionnaire (RMDQ) (Roland and Morris, 1983;Wiesinger et al., 1999;Pengel et al., 2004). ...
... Finally, NSCLBP patients constitute a heterogeneous population due to the absence of any specific aetiology (Dankaerts et al., 2006a). Kim et al., (2013) found different FR ratio asymmetry responses when NSCLBP patients were put into subgroups according to the O'Sullivan classification (Dankaerts and O'Sullivan, 2011). However, a subgroup analysis could not be performed in the present study because of the small number of participants. ...
... Concernant l'asymétrie neuromusculaire, ces adaptations semblent être symétriques entre le côté droit et le côté gauche lors d'une tâche de soulever de charge. L'amplitude de rotation plus importante et l'activation retardée des muscles stabilisateurs du rachis peuvent traduire un contrôle de mouvement réduit chez les patients atteints de NSCLBP conduisant à l'instabilité du rachis corroborant les conclusions de précédentes études (Dankaerts and O'Sullivan, 2011;Luomajoki et al., 2010bLuomajoki et al., , 2008. ...
Thesis
Les lombalgies représentent la principale cause d'invalidité dans le monde depuis 1990. Sa forme chronique (durée supérieure à 3 mois) affecte 10 à 15% des cas et représente 70 à 90% du coût total lié aux lombalgies. De plus, un diagnostic précis ne peut être obtenu que dans 10-15% des cas en raison d'un manque de connaissances de la pathophysiologie catégorisant ces lombalgies comme non-spécifiques. Chercheurs et cliniciens ont mis en avant le besoin d’identifier des sous-groupes au sein de la population lombalgique chronique non-spécifique (NSCLBP) afin d’optimiser la prise en charge thérapeutique. Dans ce contexte, un projet de classification des patients NSCLBP intégrant une approche multifactorielle a été mis en place. En effet, divers facteurs contribuent au développement et à la persistance des NSCLBP. Parmi ces facteurs, on retrouve les altérations de l’activité des muscles lombaires. Ces travaux de thèse se sont intéressés à ces altérations et représentent une partie du projet d’identification des sous-groupes.La littérature met en évidence différentes altérations dans l’activité électromyographique (EMG) des muscles lombaires chez les patients NSCLBP lors de l’exécution de plusieurs tâches fonctionnelles telles que la marche, le soulever de charge, le transfert assis-debout et encore la montée d’escaliers. Parmi ces altérations EMG, l’asymétrie neuromusculaire entre le côté droit et le côté gauche a montré une influence sur l’effet de la réhabilitation, le recrutement musculaire et la persistance de la douleur. Ces éléments font de l’asymétrie neuromusculaire un facteur important pour la compréhension de la pathophysiologie des NSCLBP. Cependant, peu d’études, à ce jour, se sont intéressées à l’asymétrie droite/gauche de l’activité des muscles lombaires. Étudier cette asymétrie pourrait permettre une meilleure compréhension de la pathophysiologie des NSCLBP.L’objectif de cette thèse était donc de caractériser l’asymétrie de l’activité des muscles lombaires lors de différentes tâches motrices et d’évaluer sa pertinence dans le processus d’identification de sous-groupes de patients NSCLBP. Pour répondre à ces objectifs, quatre études complémentaires ont été menées au cours de tâches motrices nécessitant un mouvement synchrone entre droite et gauche.Dans leur ensemble, ces travaux de thèse mettent en évidence une altération globale de l’activité EMG des muscles lombaires au cours des quatre tâches motrices étudiées que sont le test de Sorensen, la flexion antérieure maximale du tronc, le transfert assis-debout et le soulever de charge. Malgré le fait que certaines altérations permettent une augmentation de la stabilité du tronc, elles peuvent toutes avoir des conséquences nocives à long terme. L’asymétrie neuromusculaire est l’une de ces altérations mais elle ne semble présente que lors de la tâche de flexion antérieure maximale du tronc. Considérant que le projet de classification se base principalement sur les altérations observées dans la population NSCLBP, l’intégration de l’asymétrie du phénomène de flexion-relaxation peut représenter un intérêt certain dans le processus d’identification des sous-groupes. Il serait aussi pertinent d’étendre l’analyse aux muscles de l’abdomen et du bassin ainsi que d’évaluer l’influence des paramètres psychologiques pour une compréhension plus complète de ces résultats.
... The classification of MCI is based on the observation of aberrant movements accompanied by postural pain (O'Sullivan, 2005). A further sub-classification of MCI identifies the specific movement direction in which control is reduced (Dankaerts et al., 2006;Dankaerts and O'Sullivan, 2011). The subclassification categories are flexion, active extension, passive extension, lateral shift or multidirectional MCI (O'Sullivan, 2005). ...
... Age had to be 18e75 years. Eligible patients also had to present with: predefined MCI complaints (pain provocation in static positions) (Dankaerts and O'Sullivan, 2011), together with a score of two or more positive results out of the six MCI tests (Luomajoki et al., 2007). Disability levels had to be at least five points on the Roland Morris Disability Questionnaire (RMDQ) (Roland and Morris, 1983;Wiesinger et al., 1999;Pengel et al., 2004). ...
Article
Full-text available
Exercise is an effective treatment for patients with sub-acute and chronic non-specific low back pain (NSLBP). Previous studies have shown that a subgroup of patients with NSLBP and movement control impairment (MCI) can be diagnosed with substantial reliability. However, which type of exercises are most beneficial to this subgroup is still unknown. The effectiveness of a specific exercise treatment to improve movement control was tested in this study. Using a multicentre randomised controlled trial (RCT), we compared exercises that targeted MCI (MC) with a general exercise (GE) treatment. After randomisation, patients in both groups n(MC = 52; GE = 54) were treated in eight private physiotherapy practices and five hospital outpatient physiotherapy centres. Follow-up measurements were taken at post-treatment, six months and 12 months. The primary outcome measurement was the Patient Specific Function Scale (PSFS). PSFS showed no difference between groups after treatment, or at six months and 12 months. Secondary outcome analysis for pain and disability, measured with the Graded Chronic Pain scale and the Roland Morris Disability Questionnaire respectively, showed that a small improvement post-treatment levelled off over the long term. Both groups improved significantly (p < 0.001) over the course of one year. This study found no additional benefit of specific exercises targeting MCI. Copyright © 2015 Elsevier Ltd. All rights reserved.
... The classification of MCI is based on the observation of aberrant movements accompanied by postural pain (O'Sullivan, 2005). A further sub-classification of MCI identifies the specific movement direction in which control is reduced (Dankaerts et al., 2006;Dankaerts and O'Sullivan, 2011). The subclassification categories are flexion, active extension, passive extension, lateral shift or multidirectional MCI (O'Sullivan, 2005). ...
... Age had to be 18e75 years. Eligible patients also had to present with: predefined MCI complaints (pain provocation in static positions) (Dankaerts and O'Sullivan, 2011), together with a score of two or more positive results out of the six MCI tests (Luomajoki et al., 2007). Disability levels had to be at least five points on the Roland Morris Disability Questionnaire (RMDQ) (Roland and Morris, 1983;Wiesinger et al., 1999;Pengel et al., 2004). ...
Article
A b s t r a c t Background: Exercise is an effective treatment for patients with sub-acute and chronic non-specific low back pain (NSLBP). Previous studies have shown that a subgroup of patients with NSLBP and movement control impairment (MCI) can be diagnosed with substantial reliability. However, which type of exercises are most beneficial to this subgroup is still unknown. Objectives: The effectiveness of a specific exercise treatment to improve movement control was tested in this study. Methods: Using a multicentre randomised controlled trial (RCT), we compared exercises that targeted MCI (MC) with a general exercise (GE) treatment. After randomisation, patients in both groups n(MC ¼ 52; GE ¼ 54) were treated in eight private physiotherapy practices and five hospital outpatient physiotherapy centres. Follow-up measurements were taken at post-treatment, six months and 12 months. The primary outcome measurement was the Patient Specific Function Scale (PSFS). Results: PSFS showed no difference between groups after treatment, or at six months and 12 months. Secondary outcome analysis for pain and disability, measured with the Graded Chronic Pain scale and the Roland Morris Disability Questionnaire respectively, showed that a small improvement post-treatment levelled off over the long term. Both groups improved significantly (p < 0.001) over the course of one year. Conclusion: This study found no additional benefit of specific exercises targeting MCI.
... Finding the optimal sitting posture/s for an individual requires examining for motor control aberrations, muscle impairments and dysfunctional movement patterns contributing to pain production (Astfalck et al., 2010;Dankaerts et al., 2006a,b;Dankaerts and O'Sullivan, 2011;McGill et al., 2003a;McGill, 2004;O'Sullivan et al., 2013d) given that such aberrations increase muscle activity and loads, predisposing the back to further injury (McGill et al., 2003b). Other variables to consider include, but are not limited to, direction of movement that improves or worsens symptoms, physical individual ranges of motion in the thoracic and lumbar spines in sitting, the natural degree of hypo/hyperlordosis in standing and the impact that sitting, which increases lumbar kyphosis compared to standing, has on posterior tissue strain, the frequency/ease of movement permitted by the seat and tasks pursued while seated (Claus et al., 2009;Keegan, 1953;McGill, 2004;O'Sullivan et al., 2012b). ...
... Lay term advice is required that in the short term pain from sustained kyphosed sitting may be caused by creep irritating pain receptors in ligaments and lumbodorsal fascia (Callaghan and Dunk, 2002) and in the long term may be the result of accumulation of microtrauma in the ligaments (Solomonow, 2012). Kyphosis also causes decreased proprioceptive control and spinal stability, decreased resistance to damaging shear forces (McGill, 2004), reduced spinal extensor endurance and prevents movement (Dankaerts and O'Sullivan, 2011). Increasing patient awareness of the correlation between pain provoking flexion or extension movements in standing and sustaining kyphosed or hyperlordosed postures in sitting may be necessary. ...
Article
Dynamic seating design purports to lessen damage incurred during sedentary occupations by increasing sitter movement while modifying muscle activity. Dynamic sitting is currently defined by O’Sullivan et al. (2013d) as relating to ‘the increased motion in sitting which is facilitated by the use of specific chairs or equipment’ (p. 628). Yet the evidence is conflicting that dynamic seating creates variation in the sitter’s lumbar posture or muscle activity with the overall consensus being that current dynamic seating design fails to fulfill its goals. Research is needed to determine if a new generation of chairs requiring active sitter involvement fulfills the goals of dynamic seating and aids cardio/metabolic health. This paper summarises the pursuit of knowledge regarding optimal seated spinal posture and seating design. Four new forms of dynamic seating encouraging active sitting are discussed. These are 1) The Core-flex with a split seatpan to facilitate a walking action while seated 2) the Duo balans requiring body action to create rocking 3) the Back App and 4) Locus pedestal stools both using the sitter’s legs to drive movement. Unsubstantiated claims made by the designers of these new forms of dynamic seating are outlined. Avenues of research are suggested to validate designer claims and investigate whether these designs fulfill the goals of dynamic seating and assist cardio/metabolic health. Should these claims be efficacious then a new definition of dynamic sitting is suggested; ‘Sitting in which the action is provided by the sitter, while the dynamic mechanism of the chair accommodates that action’.
... Exercise prescriptions for CLBP have also been designed to address movement control impairments (MCI) (Dankaerts & O'Sullivan, 2011;O'Sullivan, 2005 (Lomond et al., 2015;Saner et al., 2015;Saner et al., 2016). Recently, a series of studies were published reporting short and long-term results of an exercise prescription based on MCI compared to a general exercise program (Saner et al., 2015;Saner et al., 2016). ...
... There are frequent examples of studies providing contemporary pain education under a biopsychosocial focus of treatment, which is paired with biomedical/reductionist exercise modes. These include 'core-informed' exercise prescriptions (Ferreira et al., 2007;Ryan et al., 2010) and protocols to address movement impairments (Dankaerts & O'Sullivan, 2011;Vibe Fersum et al., 2013). It is plausible the competing nature of the paired interventions may lead to sub-optimal patient outcomes, compared to a cohesive approach where both components of the intervention originate from the same philosophical underpinning. ...
Thesis
Full-text available
Chronic low back pain carries a large global burden of disease. Currently, exercise is recognised as a key treatment for chronic low back pain. However, management of chronic low back pain presents exercise-based practitioners with numerous, confusing, and conflicting treatment options. Broadly, these options can be classified under biomedical or biopsychosocial treatment paradigms. An overarching problem within chronic low back pain literature is the understanding of if practitioners are applying best practice approaches, and if not, how this can be improved. Based on these evident gaps in our understanding of the management of chronic low back pain, this thesis investigated the following: How do exercise-based practitioners currently manage chronic low back pain, and what attitudes and beliefs underpin this management? What does a pragmatic biopsychosocial exercise-based approach to chronic low back pain look like, and what role does exercise play in this intervention? Can education targeted at current gaps in practice by exercise-based practitioners, combined with pragmatic understanding of biopsychosocial exercise prescription, improve clinical decision making? This thesis examined chronic low back pain at the level of the patient and of the practitioner. This thesis found exercise not to be a significant factor in the design of combined exercise and education interventions for chronic low back pain. This finding allows practitioners to move away from systemised approaches to exercise for chronic low back pain and explore prescriptions optimal for the individual patient, rather than optimal for back pain in general. However, this thesis also found practitioners with biomedical beliefs, even when concomitant with biopsychosocial beliefs, are less likely to apply these contemporary approaches. Indeed, targeted education does improve clinical decision-making through a reduction in biomedical beliefs, which increases the care provided to patients. This improvement in clinical decision-making through a reduction in biomedical beliefs, and no change to biopsychosocial, may suggest the relative importance of biomedical beliefs on approaches to chronic low back pain.
... Asymmetry in the FR ratio ESL was greater in the NSCLBP group than among APs, but there was no significant difference between the groups with regard to asymmetry in the FR ratio LMF . There was no significant difference between higher-side FR ratios among APs (median [interquartile range (IQR)]) ¼ 0. 41 The FR ratio ESL was significantly and strongly correlated with thorax flexion ROM ( Figure 3A). Asymmetry in the FR ratio ESL was significantly and moderately correlated with thorax rotation ROM ( Figure 3B) and with asymmetry in trunk lateral ROM ( Figure 3C). ...
... 40 Kim et al 9 found different FR ratio asymmetry responses when patients with NSCLBP were put into subgroups according to the O'Sullivan classification. 41 However, a subgroup analysis could not be performed in the present study because of the small number of participants. ...
Article
Study design: A cross-sectional comparative study. Objective: The present study aimed to investigate the relationship between the flexion-relaxation phenomenon asymmetry of lumbar muscles and trunk lateral Range of Motion (ROM) asymmetry in non-specific chronic low back pain (NSCLBP) patients. Summary of background data: Imbalance in trunk muscle activation between right and left sides can induce pain by loading the spine incorrectly, especially in NSCLBP patients. A previous study reported a greater asymmetry in the flexion-relaxation phenomenon of the erector spinae in NSCLBP patients than in asymptomatic participants (AP). Imbalance of muscle properties, such as trunk ROM, has been suggested as a possible cause of this observed asymmetry. Methods: Twenty-eight NSCLBP patients and twenty-two AP performed three standing maximal trunk flexions. Surface electromyography were recorded bilaterally for erector spinae longissimus and lumbar multifidus. A flexion-relaxation ratio was calculated for each muscle. The fingertip-to-thigh test was performed to assess trunk lateral ROM. Each parameter's asymmetry was calculated as the absolute difference between right and left sides. Results: NSCLBP patients present a significantly lower trunk lateral ROM than AP. Flexion-relaxation ratio asymmetry of the erector spinae was significantly greater in NSCLBP patients than in AP (p < 0.05). Flexion-relaxation ratio asymmetry of the multifidus and trunk lateral ROM asymmetry were not significantly different between groups. Significant correlation (r = 0.49) between flexion-relaxation ratio asymmetry of Erector spinae and trunk lateral ROM asymmetry was observed only for NSCLBP patients. Conclusions: The present findings showed that flexion-relaxation ratio asymmetry of erector spinae longissimus is moderately correlated with trunk lateral ROM asymmetry. In addition, the results confirmed that NSCLBP patients present a reduced trunk lateral ROM, flexion-relaxation ratio asymmetry of the erector spinae which is correlated with trunk rotation. These findings suggested an imbalance spine loading which can contribute to the persistence of pain. Level of evidence: 3.
... [4] This high expenditure is largely due to numbers of lost workdays considered an indirect cost as well as direct treatment cost. [7] The high prevalence of back pain is another factor influencing the cost, with an estimated 70%-90% of any adult population experiencing at least one episode over their lifetime. LBP is the most prevalent of all musculoskeletal problems. ...
... LBP is the most prevalent of all musculoskeletal problems. [5,7,8] Over the last two decades, the prevalence of back pain and its associated costs have been increasing considerably. [9] Contemporary health care generally considers back pain to be a multidimensional problem with a multicausal etiology. ...
... Das für die LWS entwickelte, international eingesetzte Klassifikationssystem von O'Sullivan [9,10,36] besitzt eine gute Reliabilität und Validität. Es ist auch auf die HWS übertragbar [24] und ordnet Patienten einer "Movement-Impairment"-(MI)oder einer "Control-Impairment"-(CI)-Gruppe zu. ...
Article
Zusammenfassung Hintergrund Nackenschmerzen sind weltweit eine häufig auftretende Gesundheitseinschränkung. Der große Anteil von Patienten mit unspezifischen Nackenschmerzen kann in Subgruppen eingeteilt werden. Eine dieser Subgruppen sind Patienten mit Bewegungskontrollproblemen. Für eine eindeutige Identifizierung dieser Gruppe sind zuverlässige Messverfahren notwendig. Es gibt eine Vielzahl verschiedener Tests zur Überprüfung der Bewegungskontrolle. Bisher liegt kein Review über den aktuellen Forschungsstand zur Intertester- und Intratester-Reliabilität der vielen Bewegungskontrolltests ohne technische Geräte bei Patienten mit Nackenschmerzen vor. Ziel Das Ziel der Arbeit ist es, die aktuell vorhandene Evidenz zur Intratester- und Intertester-Reliabilität von Bewegungskontrolltests bei Patienten mit Nackenschmerzen zu untersuchen. Methode Die Recherche fand im April 2017 bei Medline, Cochrane und PEDro unter anderem mit den Suchbegriffen „neck pain“ [Mesh], „reproducibility of results“ [Mesh], „reliability“ und „movement control impairment“ sowie einer Vielzahl von Synonymen statt. Um das Bias-Risiko der eingeschlossenen Studien zu ermitteln, wurde die QAREL-Checkliste verwendet 17. Eine Autorin extrahierte die Studien- und Patientencharakteristika. Ergebnisse 4 Studien mit einem geringen (8/11) bis moderaten (7/11) Bias-Risiko wurden eingeschlossen. Die Intertester-Reliabilität der 26 Tests lag zwischen ausreichend und sehr gut (k = 0,32 – 1,0), die Intratester-Reliabilität der 11 Tests war moderat bis sehr gut (k = 0,59 – 0,92). Lediglich 3 Tests wurden von je 2 Studien, alle anderen Tests jeweils nur von 1 Studie überprüft. Der am besten untersuchte und beurteilte Test zur Einschätzung der Bewegungskontrolle der HWS war der Test „Blickstabilität“. Schlussfolgerung Weitere Studien sollten neben der Untersuchung der Validität einzelner Tests eine Testbatterie zur zuverlässigen Beurteilung der Bewegungskontrolle der HWS entwickeln.
... However, other movements such as side bending or rotation, may also have provoked pain responses, had they been examined. Further, examination of movement patterns previously associated with directional pain responses [41] were not examined. Inclusion criteria required participants having dominant LBP [27], minimizing the likelihood of radiculopathy which may also have influenced our findings compared to previous studies. ...
... Although the pain was also below the knee, the slump and straight leg raise tests were both negative and there were no neurological signs. Based on the painful loss of normal physiological movement in the flexion direction, the patient was then classified as "flexion pattern" of movement impairment disorder, with a combination of peripheral and central drivers of pain (Dankaerts and O'Sullivan, 2011;Vibe Fersum et al., 2009). ...
Article
This case report presents the effect of classification-based cognitive functional therapy in a patient with chronic disabling low back pain. The patient was assessed using a multidimensional biopsychosocial classification system and was classified as having flexion pattern of movement impairment disorder. Management of this patient was to change her belief that bending over and sitting would cause damage to her disc, combined with active exercises for graded exposure to lumbar flexion to restore normal movement. Three months after the first appointment, the treatment resulted in reduced pain, the mitigation of fear avoidance beliefs and the remediation of functional disability. The patient returned to work and was walking for one hour a day on a treadmill. The cognitive intervention to change the patient's negative beliefs related to the biomedical model was important to make the graded exercises and the lifestyle changes possible. Copyright © 2015 Elsevier Ltd. All rights reserved.
... However, other movements such as side bending or rotation, may also have provoked pain responses, had they been examined. Further, examination of movement patterns previously associated with directional pain responses [41] were not examined. Inclusion criteria required participants having dominant LBP [27], minimizing the likelihood of radiculopathy which may also have influenced our findings compared to previous studies. ...
... However, other movements such as side bending or rotation, may also have provoked pain responses, had they been examined. Further, examination of movement patterns previously associated with directional pain responses [41] were not examined. Inclusion criteria required participants having dominant LBP [27], minimizing the likelihood of radiculopathy which may also have influenced our findings compared to previous studies. ...
... However, other movements such as side bending or rotation, may also have provoked pain responses, had they been examined. Further, examination of movement patterns previously associated with directional pain responses [41] were not examined. Inclusion criteria required participants having dominant LBP [27], minimizing the likelihood of radiculopathy which may also have influenced our findings compared to previous studies. ...
Article
Background and aims: Provocative pain responses following standardised protocols of repeated sagittal plane spinal bending have not been reported in people with chronic low back pain (CLBP). Potential differing pain responses to movement likely reflect complex sensorimotor interactions influenced by physical, psychological and neurophysiological factors. To date, it is unknown whether provocative pain responses following repeated bending are associated with different pain sensitivity and psychological profiles. Therefore the first aim of this study was to determine whether data-driven subgroups with different, clinically-important pain responses following repeated movement exist in a large CLBP cohort, specifically using a standardised protocol of repeated sagittal plane spinal bending. The second aim was to determine if the resultant pain responses following repeated movement were associated with pain and disability, pain sensitivity and psychological factors. Methods: Clinically-important (≥2-points, 11-point numeric rating scale) changes in pain intensity following repeated forward/backward bending were examined. Participants with different provocative pain responses to forward and backward bending were profiled on age, sex, pain sensitivity, psychological variables, pain characteristics and disability. Results: Three groups with differing provocative pain responses following repeated movements were derived: (i) no clinically-important increased pain in either direction (n=144, 49.0%), (ii) increased pain with repeated bending in one direction only (unidirectional, n=112, 38.1%), (iii) increased pain with repeated bending in both directions (bidirectional, n=38, 12.9%). After adjusting for psychological profile, age and sex, for the group with bidirectional pain provocation responses following repeated spinal bending, higher pressure and thermal pain sensitivity were demonstrated, while for the group with no increase in pain, better cognitive and affective psychological questionnaire scores were evident. However, these associations between provocative pain responses following movement and pain sensitivity and psychological profiles were weak. Conclusions: Provocative pain responses following repeated movements in people with CLBP appear heterogeneous, and are weakly associated with pain sensitivity and psychological profiles. Implications: To date, suboptimal outcomes in studies examining exercise interventions targeting directional, movement-based subgroups in people with CLBP may reflect limited consideration of broader multidimensional clinical profiles associated with LBP. This article describes heterogeneous provocative pain responses following repeated spinal bending, and their associated pain sensitivity and psychological profiles, in people with CLBP. These findings may help facilitate targeted management. For people with no increase in pain, the lack of pain provocation following repeated spinal bending, in combination with a favourable psychological profile, suggests this subgroup may have fewer barriers to functional rehabilitation. In contrast, those with pain provoked by both forward and backward bending may require specific interventions targeting increased pain sensitivity and negative psychological cognitions and affect, as these may be may be important barriers to functional rehabilitation.
... To limit the potential for pain to inhibit values observed for strength and flexibility, we only tested those who reported pain intensity <3 during physical activities, one week before assessment day based on a 0-10 visual analog scale (VAS), where 10 was the worst pain imaginable and 0 was no pain (Jensen, Turner, Romano, and Fisher, 1999). Lumbar extension range of motion was not limited by pain or stiffness (Dankaerts and O'Sullivan, 2011). For the control group, participants must have reported no history of LBP or lower limb pain in the previous year. ...
Article
Objective: To compare muscle strength and flexibility among a subgroup of women with extension-related chronic nonspecific low back pain (CNLBP) with healthy controls. Methods: In this case-control study, 32 subjects with and without extension-related CNLBP were tested (n = 16 in each group). Gluteal, abdominal, paravertebral, and hamstring strength, along with hip flexor flexibility and hamstring flexibility were compared between groups. Data were analyzed using the Mann-Whitney test (p < .007). Results: The CNLBP subgroup displayed significantly lower strength of all muscles analyzed (p < .007), with the exception of gluteus medius. The flexibility of the hip flexors and hamstrings were not significantly reduced among the women with CNLBP (p > .007). Discussion: The present study showed that alterations in muscle strength, but not flexibility, partly consistent with those previously hypothesized but not objectively reported, were present among a subgroup of women with extension-related CNLBP. These results may have implications for the selection of therapeutic exercises among this subgroup of people with CNLBP.
... This case report emphasises the importance of a multidimensional biopsychosocial approach as one method for assessing and treating LBP (Dankaerts and O'Sullivan, 2011). This patient was told that surgery would be the only way to treat the cause of the problem. ...
Article
This case report presents the effect of Cognitive Functional Therapy (CFT) in a patient with chronic non-specific low back pain associated with unilateral loading impairment of the left lower limb. The patient believed surgery was the only possible way to treat the cause of the problem. The management of this idea was to change such belief. Manual therapy and active exercises were combined in order to encourage the patient to trust his back and lower limb again. One month and a half after the first appointment, the treatment resulted in complete absence of pain and disability. The patient returned to work and he was able to climb stairs and load his left limb normally.
... Because these patients cannot control their movement properly they might themselves unknowingly be increasing their pain [20]. The subgrouping system of O'Sullivan shows high reliability [22]. For the movement control subgroup a test battery has been proposed which demonstrates adequate discriminative validity [23]. ...
Article
Full-text available
Background: Clinical guidelines recommend research on sub-groups of patients with low back pain (LBP) but, to date, only few studies have been published. One sub-group of LBP is movement control impairment (MCI) and clinical tests to identify this sub-group have been developed. Also, exercises appear to be beneficial for the management of chronic LBP (CLBP), but very little is known about the management of sub-acute LBP. Methods: A randomized controlled trial (RCT) was conducted to compare the effects of general exercise versus specific movement control exercise (SMCE) on disability and function in patients with MCI within the recurrent sub-acute LBP group. Participants having a MCI attended five treatment sessions of either specific or general exercises. In both groups a short application of manual therapy was applied. The primary outcome was disability, assessed by the Roland-Morris Disability Questionnaire (RMDQ). The measurements were taken at baseline, immediately after the three months intervention and at twelve-month follow-up. Results: Seventy patients met the inclusion criteria and were eligible for the trial. Measurements of 61 patients (SMCE n = 30 and general exercise n = 31) were completed at twelve months. (Drop-out rate 12.9 %). Patients in both groups reported significantly less disability (RMDQ) at twelve months follow-up. However, the mean change on the RMDQ between baseline and the twelve-month measurement showed statistically significantly superior improvement for the SMCE group -1.9 points (-3.9 to -0.5) 95 % (CI). The result did not reach the clinically significant three point difference. There was no statistical difference between the groups measured with Oswestry Disability Index (ODI). Conclusion: For subjects with non-specific recurrent sub-acute LBP and MCI an intervention consisting of SMCE and manual therapy combined may be superior to general exercise combined with manual therapy. Trial registration: The study protocol registration number is ISRCTN48684087 . It was registered retrospectively 18th Jan 2012.
... Because these patients cannot control their movement properly they might themselves unknowingly be increasing their pain [20]. The subgrouping system of O'Sullivan shows high reliability [22]. For the movement control subgroup a test battery has been proposed which demonstrates adequate discriminative validity [23]. ...
... There are some studies that show the role of hip extensor muscles in lower back stabilization as well as in lumbopelvic rhythm (29). At the end of trunk flexion, the movement is finishing, but because of maladaptive motor control, excessive movement occurs in the lumbar spine (23). In this condition, CNS probably tries to stop the movement by limiting the hip motion. ...
Article
Background: Static and dynamic postures of lumbopelvic in low back pain (LBP) are considered as two important aspects of clinical assessment and management of LBP. Thus, the focus of the current study was to compare the posture and compensatory strategy of hip and lumbar region during trunk flexion between LBP subgroupsand health subjects. LBP cases are subdivided into active extension pattern (AEP) and flexion pattern (FP) based on O'Sullivan's classification system (OCS). Methods: This work was a cross-sectional study involving 72 men, 21 low back pain patients with FP and 31 low back pain patients with AEP and 20 healthy groups. Lumbar and hip angles during trunk flexion were measured by a 3D motion analysis system in neutral standing posture and end-range of trunk flexion. The participants were asked to full bend without any flexion of the knees. The bending speed was preferential. Hip and lumbar ranges of motion were divided into four quartiles (Q). The quartiles were compared between groups. Data analysis was performed using one-way analysis of variance (ANOVA) and independent t-test. Results: There was no statistically significant difference in lumbar lordosis in standing and full trunk flexion positions between the healthy groups and heterogeneous LBP groups. In addition, there was not any statistically significant difference between the healthy group and the homogenous LBP group (FP and AEP). Moreover, no statistically significant difference was observed in hip angles during standing between the healthy group and the heterogeneous LBP group, and between the healthy group and the homogenous LBP group (FP and AEP). In full trunk flexion position, there was statistically significant difference in hip angles between the healthy group and the heterogeneous LBP group (P=0.026). In this position, the difference in hip angles between the healthy group and FP group was statistically significant (P<0.05). In the second Q, there was no significant difference between the healthy group and the heterogeneous LBP group (P=0.062), however, there was a significant difference between FP group and the healthy group in the fourth Q of the total hip range of motion. There was no statistically significant difference between the healthy group and the heterogeneous LBP group (P=0.054) but there was a difference between FP group and the healthy group. Lumbar/hip motion ratio (L/H ratio) was different between and within the subgroups in the second Q. Conclusion: This study supported the subgrouping of LBP and showed that the difference between subgroups could be determined effectively through subdividing the total range of lumbar and hip motions into smaller portions. It is possible that the neuromuscular system selects different strategies to compensate and prevent further injury of the chain components (muscle, joint, nerve and etc.). Level of evidence: IV.
... The STarT (Subgroups for Targeted Treatment) Back Screening Tool has attracted considerable attention in recent years and can be used, among other tools, to create subgroups of patients with NSCLBP [16,17]. Furthermore, O'Sullivan et al. developed a CLBP classification system with sufficient interrater reliability and validity [11,[18][19][20][21]. Based on clinical patterns, this system classifies patients into three subgroups [11]: ...
... As part of this, participants underwent a standard evaluation according to the O`Sullivan classification model for patients with CLBP by two therapists who completed a threeday workshop on the O`Sullivan classification. The reliability of the O`Sullivan classification system has already been approved (19,20). Overall inclusion criteria consisted of the following: at least three years of experience playing volleyball and at least three training sessions/week in volleyball, at least a three-month history of LBP, pain in the lumbar region increases with lumbar extension movements and decreases with lumbar flexion movements, lumbar range of motion was not being restricted due to pain or joint stiffness. ...
Article
Full-text available
Background. The kinematics of a controlled functional task in female volleyball athletes may be an interesting area of study. Therefore, investigating if there are kinematic changes in a jump landing jump task among female athletes with low back pain (LBP) may help therapists and trainers better prevent and/or rehabilitate LBP in athletes. Objectives. The purpose of this study was to examine lumbopelvic and lower extremity kinematics in athletes with persistent LBP during a jumping task. Methods. A comparative cross sectional study conducted in a university research laboratory. Professional female volleyball players with (n = 20) and without (n = 18) LBP were recruited from the Iranian female volleyball league. To reduce heterogeneity, one particular subgroup of athletes with LBP were selected. Kinematic data including lumbar extension, hip flexion, rotation and adduction and knee flexion and abduction angles when the center of mass was at minimum height during a jump-landing-jump maneuver were collected using a Vicon motion analysis system and analysed using MATLAB software. Independent t-tests were used to compare mean values between the groups. Results. Athletes with LBP had significantly greater hip flexion (LBP: -73.62±11.06˚; Control: -62.88±7.03˚, p=0.016) and significantly less knee flexion (LBP: 77.06±7.27 ˚, Control: 81.62±4.70 ˚, p=0.029) at the lowest point of the jump than athletes without LBP. There were no other significant differences between the groups (p>0.05). Conclusion. A subgroup of female athletes with LBP display altered lower extremity kinematics during a jump task than athletes without LBP. This may have important implications for lower limb performance and injury.
... For each patient their vicious cycle of pain was explained in a personalised diagram based on their assessment findings. Specific movement exercises designed to normalise their maladaptive movement behaviours were given based on developed by O'Sullivan [55], whilst the others looked at classifying patients for motor control [56] and Sahrmann's movement impairment syndromes [57]. ...
Article
Full-text available
CLBP is the leading cause of years lived with disability worldwide and patients with yellow flags have the worst outcomes and contribute significantly to the societal cost. Clinicians are aware of the importance of yellow flags but feel undertrained to deal with them. Furthermore there is a lack of clarity for clinicians looking at how to specifically manage these patients from guidelines and an incredibly varied set of approaches available to clinicians. The objective of this review was to review the effectiveness of the physiotherapy interventions for chronic low back pain patients with yellow flags that have been studied. Three approaches were used for retrieving literature. Searches were conducted initially using the terms "physiotherapy", "chronic low back pain", psychosocial and "management or treatment", using the databases PubMed, Embase, PEDro and CINHAL from January 1987 up to February 2017. In addition content experts were consulted to ensure no additional papers were missed and citation tracking was implemented. 39 studies were identified with 20 meeting the selection criteria. Interestingly the term yellow flags is not used in the treatment literature and instead specific psychosocial terms are used. This review tentatively suggests specific exercise and passive interventions are more beneficial for reducing measures of pain, whilst psychological input and general exercise appears more targeted towards psychosocial measures.
... It has been demonstrated that not only personal fitness but also psychological and emotional states may influence pain perception [8], and these could be integrated during a TE programme [14][15][16][17][18][19]. Furthermore, functional cognitive therapy has been proven as effective in overcoming the fear of movement displayed by chronic musculoskeletal disease sufferers by reshaping their attitudes and beliefs about their pain [20,21]. Specifically in respect to therapeutic physical exercise in water, some modalities such as adapted swimming are presented as a feasible clinical practice for patients with CNSNP, eliminating fear of movement as it is an accessible and fun activity [22]. ...
Article
Full-text available
The aim of this study was to analyse the effect of an 8-week multimodal physiotherapy programme (MPP), integrating physical land-based therapeutic exercise (TE), adapted swimming and health education, as a treatment for patients with chronic non-specific neck pain (CNSNP), on disability, general health/mental states and quality of life. 175 CNSNP patients from a community-based centre were recruited to participate in this prospective study. 60-minute session (30 minutes of land-based exercise dedicated to improving mobility, motor control, resistance and strengthening of the neck muscles, and 30 minutes of adapted swimming with aerobic exercise keeping a neutral neck position using a snorkel). Health education was provided using a decalogue on CNSNP and constant repetition of brief advice by the physiotherapist during the supervision of the exercises in each session. primary: disability (Neck Disability Index); secondary: physical and mental health states and quality of life of patients (SF-12 and EuroQoL-5D respectively). Differences between baseline data and that at the 8-week follow-up were calculated for all outcome variables. Disability showed a significant improvement of 24.6% from a mean (SD) of 28.2 (13.08) at baseline to 16.88 (11.62) at the end of the 8-week intervention. All secondary outcome variables were observed to show significant, clinically relevant improvements with increase ranges between 13.0% and 16.3% from a mean of 0.70 (0.2) at baseline to 0.83 (0.2), for EuroQoL-5D, and from a mean of 40.6 (12.7) at baseline to 56.9 (9.5), for mental health state, at the end of the 8-week intervention. After 8 weeks of a MPP that integrated land-based physical TE, health education and adapted swimming, clinically-relevant and statistically-significant improvements were observed for disability, physical and mental health states and quality of life in patients who suffer CNSNP. The clinical efficacy requires verification using a randomised controlled study design. ClinicalTrials.gov NCT02046876.
... Furthermore, lumbar extension range of motion should not be restricted because of pain or stiffness. This is consistent with selecting a homogenous "active extension: motor control impairment" subgroup of people with LBP (Dankaerts and O'Sullivan, 2011). ...
Article
Purpose: The purpose of this study was to compare kinematics of the lower extremity and lumbar spine during a single leg landing task between female volleyball athletes with and without persistent low back pain (LBP). Methods: In this cross sectional study, 36 volunteer female volleyball athletes with (n = 18) and without (n = 18) LBP were recruited. Two specifically trained physical therapists selected only athletes with a specific movement-based subgroup of LBP for inclusion. Three dimensional kinematic and ground reaction force data were recorded for each athlete across three single leg landing trials by utilizing a Vicon 6-camera motion capture system and one in-floor embedded Kistler force plate, respectively. Independent t-tests compared data between the two groups. Results: Lumbar lordosis when standing (p = 0.046) as well as on initial contact (p = 0.025) and at the time which the maximal vertical ground reaction force occurred (p = 0.020) were significantly greater in the LBP group. There were no other significant differences. Conclusions: The tendency for this specific subgroup of athletes to consistently adopt more extended lumbar postures in both static and dynamic tasks may be worth considering by those involved in coaching, performance optimizing and injury prevention.
... Because of the high prevalence of these two disorders, subjects with either FP or AEP were chosen [9,21]. Previous research has shown a substantial agreement between clinicians upon the classification of NS-CLBP with MCI supporting its intra-rater reliability [22]. Inclusion and exclusion criteria are summarized in Table 1. ...
Article
Full-text available
Objective: Non-specific chronic low back pain (NS-CLBP) has been related to abnormal trunk muscle activations, but literature reported considerable variability in muscle amplitudes of NS-CLBP patients during prolonged sitting period. Therefore, the pur- pose of this study was to examine the differences among homogenous NS-CLBP subgroups in muscle activity, using muscle co-contraction indices as a more objective approach, and their roles on pain development during a 1-hour of prolonged sitting task Design: Cross-sectional study. Methods:TwentyNS-CLBPsubjectswithmotorcontrolimpairment(MCI)[10classifiedashavingflexionpatterndisorder,and 10 with active extension pattern disorder], and 10 healthy controls participated in the study. Subjects followed a 1-hour sitting pro- tocol on a standard office chair. Four trunk muscle activities including amplitudes and co-contraction indices were recorded using electromyography over the 1-hour period. Perceived back pain intensity was recorded using a numeric pain rating scale every 10 minutes throughout the sitting period. Results:Allstudygroupspresentedwithnosignificantlydistinctivetrunkmuscles’activitiesatthebeginningofsitting(p>0.05), nor did they change over time when pain increased to a significant level (p>0.05). Both MCI subgroups reported a similarly sig- nificant increase in pain through mid-sitting (p<0.001). However, after mid-sitting, they significantly differed from each other (p<0.01) in pain but did not differ in the levels of muscle activation. Conclusions: This study was the first to highlight the similarities in trunk muscle activities among homogenous NS-CLBP pa- tients related to MCI and compared them healthy controls while sitting for an extended period of time, and the significant increase in pain over the 1-hour sitting might not be attributed to trunk muscles’ activation. Key Words: Classification, Electromyography, Low back pain, Sitting position
... Only subjects with FP or AEP, in which both therapists were in agreement, were included in the study. Previous research reported a substantial agreement between therapists upon the classification of NSCLBP with MCI advocating its intra-rater reliability (25,26). ...
Preprint
Background: Although, non-specific chronic low back pain (NSCLBP) has been associated with abnormal lumbosacral kinematics, little is known about the possible driving mechanisms of pain development overtime during prolonged sitting period. Therefore, the purpose of this study was to examine the differences in lumbosacral postures in adults with and without NSCLBP, and their role on pain development during a 1-hour of prolonged sitting task. Methods: Twenty NSCLBP subjects with motor control impairment (MCI) [10 classified as having flexion pattern (FP) disorder, and 10 with active extension pattern (AEP) disorder], and 10 healthy controls participated in the study. Subjects underwent a 1-hour sitting protocol on a standard office chair. Lumbosacral postures including: sacral tilt (ST), third lumbar vertebrae (L3) position, and relative lower lumbar angle (RLLA) were recorded using a two-dimensional inclinometer over the 1-hour period. Perceived back pain intensity was recorded using a numeric pain rating scale every 10 minutes throughout the sitting period. Results: All study groups presented with significantly distinctive lumbosacral kinematics at the lowest level of pain (the beginning of the sitting period) (p
... The STarT (Subgroups for Targeted Treatment) Back Screening Tool has attracted considerable attention in recent years and can be used, among other tools, to create subgroups of patients with NSCLBP [16,17]. Furthermore, O'Sullivan et al. developed a CLBP classification system with sufficient interrater reliability and validity [11,[18][19][20][21]. Based on clinical patterns, this system classifies patients into three subgroups [11]: ...
Article
Full-text available
Background: Nonspecific chronic low back pain (NSCLBP) is a heterogeneous condition that is associated with complex neuromuscular adaptations. Exercise is a widely administered treatment, but its effects are small to moderate. Tailoring patient-specific exercise treatments based on subgroup classification may improve patient outcomes. Objective: In this randomised controlled pilot study, our objective was to compare the feasibility and possible effects of a specific sensorimotor treatment (SMT) with those of a general exercise (GE) programme on patients with NSCLBP and control impairment (CI). Methods: Patients with NSCLBP and CI were randomised into an SMT or a GE programme spanning 6 sessions each. The feasibility criteria included the study design, assessments, interventions and magnitudes of effects, and costs. Adverse events were documented. Primary (pain, physical function, and quality of life) and secondary outcomes were assessed three times: twice at baseline (t1a and t1b) to estimate parameter stability and once after the intervention (t2). Results: Two-hundred and twenty-seven patients were screened to include 34 participants with NSCLBP and CI. Both treatment programmes and the assessments seemed feasible because their durations and contents were perceived as adequate. The total cost per participant was €321. Two adverse events occurred (one not likely related to the SMT, one likely related to the GE intervention). The SMT showed a tendency for superior effects in terms of pain severity (SMT t1a 3.5, t2 1.1; GE t1a 3.0, t2 2.0), pain interference (SMT t1a 1.9, t2 0.4; GE t1a 1.5, t2 0.9), physical component of quality of life (SMT t1a 39, t2 46; GE t1a 45, t2 48), and movement control. Conclusions: The SMT approach proposed in this study is feasible and should be tested thoroughly in future studies, possibly as an addition to GE. To ensure the detection of differences in pain severity between SMT and GE in patients with NSCLBP with 80% power, future studies should include 110 patients. If the current results are confirmed, SMT should be considered in interventions for patients with NSCLBP and CI. Trial registration: Registered in the German Register for Clinical Trials (Trial registration date: November 11, 2016; Trial registration number: DRKS00011063; URL of trial registry record); retrospectively registered.
... On the other hand, Dankaers (2011) 31 has identified some distinct patterns based on the direction where the motion is lost, where motor control is working properly motor control. This identifies the inflection patterns, active and passive extension, lateral tilt and multidirectional patterns. ...
... Although individuals without LBP might present with a specific feature (such as flexion of the spine during lifting), that does not preclude the possibility that that this feature of movement is problematic and provocative of symptoms for an individual with LBP. It is well known that individuals with LBP that adopt different movement patterns, and in some cases a cluster of movement and posture features are identified that can be used to allocate individuals to subgroups (64,70,71). It is plausible that continuous assessment of movement and posture in the real-world enabled by advances in wearable technology might reveal an association between specific postures and movements and fluctuations of the condition for an individual and provide meaningful guidance for treatment selection. ...
Article
Objective: This review aimed to: (I) provide a brief overview of some topical areas of current literature regarding applications of wearable sensors in the management of low back pain (LBP); (II) present a vision for a future comprehensive system that integrates wearable sensors to measure multiple parameters in the real world that contributes data to guide treatment selection (aided by artificial intelligence), uses wearables to aid treatment support, adherence and outcome monitoring, and interrogates the response of the individual patient to the prescribed treatment to guide future decision support for other individuals who present with LBP; and (III) consider the challenges that will need to be overcome to make such a system a reality. Background: Advances in wearable sensor technologies are opening new opportunities for the assessment and management of spinal conditions. Although evidence of improvements in outcomes for individuals with LBP from the use of sensors is limited, there is enormous future potential. Methods: Narrative review and literature synthesis. Conclusions: Substantial research is underway by groups internationally to develop and test elements of this system, to design innovative new sensors that enable recording of new data in new ways, and to fuse data from multiple sources to provide rich information about an individual's experience of LBP. Together this system, incorporating data from wearable sensors has potential to personalise care in ways that were hitherto thought impossible. The potential is high but will require concerted effort to develop and ultimately will need to be feasible and more effective than existing management.
... The identification of subgroups requires clinically feasible and reliable screening procedures (Foster et al., 2011). The validity of the clinical diagnosis of the subgroup with MCI and its functional representation is gaining increasing support (Dankaerts and O'Sullivan, 2011;Fersum et al., 2009). To further improve the screening procedure for MCI, six active movement tests have been identified in a previous study which showed substantial intra-and interrater reliability and represent the clinical classification as described above (Luomajoki et al., 2007); validity of the test series was supported by research, showing that two or more positive tests, out of a total of six tests, could distinguish between patients with LBP and healthy controls (Luomajoki et al., 2008). ...
Thesis
Full-text available
This thesis on the study of the efficacy of orthopaedic manual therapy (OMT) for patients with nonspecific low back pain (LBP) was developed by following the steps of an evidence-based practice process through three major sections. The Introduction defines the debilitating disorder of LBP and OMT, and describes an integrative approach for the stratification of care in LBP patients. Section 1 presents a systematic review that updates the best evidence of OMT efficacy in terms of pain, functions, activities and participation. The findings allow us: (I) to establish different levels of evidence for this form of therapy, (II) to understand the complexity of LBP and (III) to affirm the importance of the study design quality in OMT trials (e.g. splitting design, complexity of the placebo procedure and integration of clinical reasoning). Section 2, which is composed of three studies, investigates a kinematic model of the spine to help in the diagnosis of LBP patients, as well as outcome measures for future investigations of OMT in LBP patients. This kinematic tool permits a valid assessment of body structures (lumbopelvic and thoracic vertebral column, muscles of the trunk and pelvic regions), body functions (mobility in a vertebral segment, control of complex voluntary movements, proprioceptive function) and activities (bending, maintaining a body position). Finally, Section 3 presents two clinical studies. The first is a reliability study on a standardised and original pain provocation examination of the lumbar spine in a combined movement fashion. This examination provides the direction and vertebral level(s) of treatment. On the basis of this reliable objective examination and evidence described throughout this thesis, a randomised controlled trial was conducted. This last study questions the short-term efficacy of a novel form of OMT, namely mobilisation with movement, on primary kinematic outcome measures (kinematic algorithms for range of motion and speed) and secondary self-reported outcome measures (pain, function, activities and participation) in LBP patients with a mechanical pain pattern in flexion. The results of this investigation raise the overall level of evidence from limited to moderate in favour of using central sustained natural apophyseal glides in LBP patients. In conclusion, the different points and perspectives developed along this thesis contribute towards solving the complex puzzle of LBP within a patient-centred approach. Manual therapy is an art developed through clinical practice, as well as a science developed through fundamental and clinical research. Clinical research is of major importance because it directly drives clinical practice and education towards an evidence-based OMT practice within the biopsychosocial framework, thereby aiding many patients, students and health professionals.
Article
Study Design. Systematic review and meta-analysis. Objective. To evaluate if patients with nonspecific chronic low back pain (NSCLBP) show a greater lumbar reposition error (RE) than healthy controls. Summary of Background Data. Studies on lumbar RE in patients with NSCLBP present conflicting results. Methods. A systematic review and meta-analysis of the available literature were performed to evaluate differences in RE between NSCLBP patients and healthy controls. Data on absolute (AE), constant (CE) and variable error (VE) were extracted and effect sizes (ES) were calculated. For the CE flexion pattern and active extension pattern, subgroups of patients with NSCLBP were analyzed. Results of homogeneous studies were pooled. Measurement protocols and study outcomes were compared. The quality of reporting and the authors[spacing acute] appraisal of risk of bias were investigated. Results. The original search revealed 178 records of which 13 fulfilled the inclusion criteria. The majority of studies showed that patients with NSCLBP produced a significantly larger AE (ES 0.81 [CI .13-1.49]) and VE (ES 0.57 [CI 0.05-1.09]) compared to controls. CE is direction- specific in flexion and active extension pattern subgroups of patients with NSCLBP (ES 0.39 [CI -1.09-0.3] and ES 0.18 [CI -.3-0.65], respectively). The quality of reporting and the authors' appraisal of risk of bias varied considerably. The applied test procedures and instrumentation varied between the studies, which hampered the comparability of studies. Conclusions. Whilst patients appeared to produce a larger lumbar RE compared to healthy controls, study limitations render firm conclusions unsafe. Future studies should pay closer attention to power, precision and reliability of the measurement approach, definition of outcome measures and patient selection. We recommend a large, well powered, prospective randomised control study which uses a standardized measurement approach and definitions for AE, CE, and VE to address the hypothesis that proprioception may be impaired with CLBP.
Article
The aim of this study was to determine if differences exist in lumbar multifidus (LM) thickness at rest and during activation, between individuals with chronic low back pain (CLBP) and controls. Lumbar multifidus thickness was assessed via rehabilitative ultrasound imaging (RUSI), and was performed in prone and standing both at rest and during muscle activation i.e. with a contralateral arm lift (CAL). Twenty participants were assessed; ten CLBP participants and ten controls. Rehabilitative ultrasound imaging was used to measure LM thickness and percentage thickness change at L4/L5 and L5/S1 in four positions; prone at rest, prone during activation with a CAL, standing at rest, and standing during activation with a CAL. Independent and paired t-tests were used to calculate differences in LM thickness and percentage thickness change between groups, and also between sides in the CLBP group. There was a significant difference in LM percentage thickness change in standing during activation with a CAL; the CLBP demonstrated a greater percentage thickness increase at L5/S1 compared to the controls, (p = 0.05). There were no differences between groups at the L4/L5 level for this position. There were no differences between the groups for LM thickness or percentage thickness change in prone or standing at rest, or during activation with a CAL in prone. Within the CLBP group, no significant between side differences were found. These results give preliminary insight into possible differences in LM contractile behaviour during functional movements in CLBP, however, larger scale research is warranted.
Article
The biopsychosocial mechanisms for therapeutic effect in an osteopathic treatment encounter for people with somatic pain were reviewed and discussed in Part 1 of this article. The author argued that both biological and psychosocial therapeutic mechanisms are potentially important in clinical practice, although the relative importance of these mechanisms differs depending on the person's presentation and the nature and chronicity of the involved pain. In Part 2, clinical implications of the differing processes of pain and therapeutic mechanisms of osteopathic techniques are discussed. A rationale is presented for osteopathic management based on an understanding of the likely biological and psychological factors present and for the complementary actions of manual therapy with a cognitive behavioural approach to pain and disability. Appropriate communication, reassurance, education, and empowerment can result in positive attitudes and behaviours to pain and complement the specific biological effects of osteopathic manipulative treatment. This article will aid the clinical reasoning process and provide guidance to osteopaths for treatment selection based on patient presentation and the likely biological and psychological factors involved in pain and disability.
Article
This report describes the case of a 52 year old male administrative assistant presenting with symptomatic lumbar spinal stenosis (LSS). Despite patho-anatomical considerations, the patient's pain related functional behaviour, mal-adapted presentation, motor control strategies, incorrect belief system, and faulty cognition of associating disc healing with a lordotic posture adversely contributed to his presentation. With limited specific guidelines in the literature for this specific lumbar spine condition, the patient response during the assessment guided the intervention. Treatment that incorporated a cognitive functional therapy resulted in a successful outcome. The patient attended for twelve treatment sessions in three months and demonstrated improvement in overall function. By week 12, the Oswestry Disability Index (ODI) reduced from 68% to 19% and further reduced to 15% at three months following discharge. The patient's self-reported tolerance for standing improved from 10 min to 60 min and his self-reported tolerance of walking improved from 200 m to three kilometres. The effects were maintained three months post discharge. This case report supports the clinical utility of a patient-centred multidimensional classification system that utilised cognitive functional therapy in a patient with LSS.
Physiotherapists lack confidence in managing patients with shoulder problems, partly as a result of the complexity of presentation and lack of clear understanding of the pathology. Recently, tendon pathology has been proposed to occur in a continuum, with pathologic, imaging, and clinical evidence to support the hypothesis. Rotator cuff pathology in the older population has been demonstrated to relate to a primary degenerative tendinopathy, similar histologically and clinically to degenerative tendinopathies elsewhere in the body. Evidence to support degenerative tendinopathy as the primary pathology within the subacromial space is growing. Building on this evidence and hypothesis, a model of rotator cuff tendinopathy is presented, with suggestions for conservative management of each stage within the tendinopathy continuum based on tendinopathy management elsewhere in the body. Attention to contributing biomechanical, motor control, muscular strength and endurance, external pain referral, metabolic and psychosocial factors by physiotherapists is discussed within the context of the evidence in support of physiotherapy management of rotator cuff disorders. The current lack of research evidence in support of the proposed treatment protocol is acknowledged.
Article
Background: Altered movement patterns with pain have been demonstrated in children, adolescents and adults with chronic disabling low back pain (CDLBP). A previously developed classification system has identified different subgroups including active extension and multidirectional patterns in patients with CDLBP. While familial associations have been identified for certain spinal postures in standing, it is unknown whether a familial relationship might exist between movement pattern-derived subgroups in families with CDLBP. Objectives: This study explored whether familial associations in movement pattern-derived subgroups within and between members of families with CDLBP existed. Design: Cross-sectional cohort study. Method: 33 parents and 28 children with CDLBP were classified into two subgroups based on clinical analysis of video footage of postures and functional movements, combined with aggravating factors obtained from Oswestry Disability Questionnaire. Prevalence of subgroups within family members was determined, associations between parent and child's subgroup membership was evaluated using Fisher's exact test, and spearman's correlation coefficient was used to determine the strength of association between familial dyads. Results: The majority of parents were classified as active extenders, sons predominately multidirectional and daughters were evenly distributed between the two subgroups. No significant association was found when comparing subgroups in nine parent-child relationships. Conclusions: The exploration of a small cohort of family dyads in this study demonstrated that children's movement pattern-derived subgroups could not be explained by their parents' subgroup membership. These results cannot be generalised to the CLBP population due to this study's small sample. Larger sample studies are needed to further elucidate this issue.
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Background: Alterations in the neuromuscular control of the spine were found in patients with chronic low back pain (CLBP). Sudden loading of the spine is assumed to be the cause of approximately 12% of lower back injuries. However, some aspects of this problem, such as alterations in the sensory-motor control of the spine, remain questionable. This study investigated postural and neuro- motor changes in trunk muscles during sudden upper limb loading in patients with CLBP. Methods: Electromyography of the erector spinae (ES) and transverses abdominis/internal oblique (TrA/IO) and external oblique (EOA) muscles were recorded in 20 patients with CLBP and 20 asymptomatic individuals with eyes open (EO) and eyes closed (EC) conditions. Moreover, measurements of the center of pressure (COP) and vertical ground reaction force (GRF) or Fz were recorded using a force plate. Data were analyzed using paired t-test and independent t-test at the significance level of 0.05. Results: In patients with CLBP, decreased electrical activity of the ES muscle was observed under both the EO and EC conditions and that of the TrA/IO muscle was observed under the EO condition (p< 0.05). Other findings included a shorter peak latency of the ES muscle in the EO condition and a greater increase in the peak latency of the ES muscle following the EC condition (p< 0.05). No significant differences were observed in COP and GRF measurements between the groups. Conclusion: Electrical muscle activity may indicate less stiffening or preparatory muscle activity in the trunk muscle of patients with CLBP. Altered latency of the muscle may lead to microtrauma of lumbar structures and CLBP.
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http://findresearcher.sdu.dk/portal/files/78496193/PhD_Rune_Mygind_Mieritz.pdf
Article
The label " non-specific " that applies to 85 % of patients complaining of low back pain is an heterogeneous group including different phenotypes. The identification of the anatomic origin of pain is often impossible in a primary care encounter. However, the physician can identify several elements that are useful to establish some diagnosis, foresee the evolution and tailor therapeutic decisions.
Article
Objectives: To preliminarily investigate in patients with a primary complaint of non-acute knee pain for ≥ 1 month: 1) the proportion of patients with non-acute knee pain classified by Mechanical Diagnosis and Therapy (MDT) as Spinal Derangements, 2) the number of sessions taken to identify the concluding classification, and 3) the ability of MDT classifications, demographics, and symptomatic baselines to predict pain reduction at 1-month follow-up.Methods: This study reviewed data from outpatients managed with MDT. For modeling knee pain reduction at the 1-month follow-up, 3 MDT provisional or concluding classifications (Spinal Derangement, Knee Derangement, and Non-Derangement) and the following variables were included: 1) gender, 2) symptom duration, 3) presence of low back pain (LBP), 4) the Japanese Knee Osteoarthritis Measure, 5) average pain intensity at the initial session using a 0–10 numerical rating scale, and 6) the Kellgren–Lawrence grade.Results: Data from 101 patients were extracted. The percentage of patients with the concluding classification of Spinal Derangement was 44.6%. This was greater in those patient’s reporting concomitant LBP (p = .002) and without radiographic findings of knee osteoarthritis (p < .001). A concluding classification was determined by the fourth session in 80% of patients. Multiple regression modeling demonstrated that only the concluding classification significantly predicted the knee pain reduction at the 1-month follow-up.Discussion: These findings suggest the importance of careful screening assessments of the lumbar spine and the importance of detecting Derangements throughout the follow-up sessions for patients with a primary complaint of knee pain.
Chapter
Physical activity during pregnancy is recommended and has been shown to benefit most women. However, some modification to exercise routines may be necessary due to normal anatomic and physiologic changes and fetal requirements. Therefore, knowledge about the systemic changes of pregnancy should be taken into account when counseling women who wish to exercise through their pregnancy and should be complemented by the knowledge about the potential effect of exercise (therapeutic exercise) for prevention and resolution of some common pregnancy-related musculoskeletal conditions. Therapeutic exercise is the systematic and planned performance of exercises which aims to improve and restore physical function.
Article
Résumé La reconstruction posturale est une méthode de kinésithérapie. La place de l’analyse morphologique est prépondérante dans le raisonnement clinique et dans l’élaboration d’une stratégie thérapeutique adaptée. L’outil thérapeutique s’apparente au concept de motor overflow. Dans le cas présenté, une amélioration des plaintes algofonctionnelles est décrite.
Article
Background: Changes in the motor control of the spine were found in patients with chronic low back pain (CLBP). Sudden loading of the spine is supposed to be the cause of about 12% of lower back injuries. However, some aspects of this problem, such as alterations in the sensory-motor control of the spine, remain questionable. Objective: To investigate the effects of familiarization with loading, weight and size of loading on neuromuscular responses during sudden upper limb loading in CLBP patients. Methods: In this quasi-experimental study surface electromyography of the erector spinae (ES) and transverses abdominis/internal oblique (TrA/IO) and external oblique (EOA) muscles were recorded in 7 men and 13 women with CLBP and 20 asymptomatic subjects (10 men and 10 women) aged 18-45 years from the general community familiarization. Moreover, investigating control of the posture measurements of the center of pressure (COP) and vertical ground reaction force (GRF) or Fz were recorded using a force plate. Data were analyzed using paired t-test and independent t-test with the significance level of 0.05. Results: Data analyses were performed using SPSS version 18. Some electromyography and force plate variables were significantly different for different conditions in each group and between the asymptomatic and low back pain groups (p⩽ 0.05). Conclusion: Several motor control changes were observed in the CLBP patients. These patients showed decreased trunk muscle activity as well as too early and too delayed responses compared to asymptomatic subjects.
Article
Introduction An estimated 29% of the population, around 17.8 million people, live with a musculoskeletal condition in the UK. Pilates exercise has positive benefits, including reducing pain and disability for people with musculoskeletal conditions. The aim of the present study was to explore the views of Pilates‐trained physiotherapists in relation to the perceived benefits of, and clinical reasoning for, exercise prescription in Pilates classes. Methods A qualitative approach was taken to both data collection and analysis, using a thematic framework. Data were collected via electronic questionnaires using open‐ended questions. Participants included 15 Pilates‐trained physiotherapists who regularly ran Pilates exercise classes within seven private physiotherapy clinics for people with a range of chronic musculoskeletal conditions. Results The results were organized into six main themes: Perceived benefits 1: Improved function and increased levels of activity. Perceived benefits 2: Improved ability to manage their musculoskeletal condition autonomously; Efficacy of group Pilates exercise; Optimum combination of exercises used within a class; Physiotherapist rationale for the most effective exercises; Precautions with specific exercises. Conclusions The study was the first to investigate perceived benefits, rationale and preference for choice of exercise among Pilates‐trained physiotherapists. Physiotherapists felt that the Pilates classes facilitated an active lifestyle and self‐management approach. They used a combination of exercises in each class to address all the main muscle groups, but some had specific exercise preferences related to the patients' needs. Exercises were linked to evidence around neuromuscular control, direction preference and biomechanical principles.
Article
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Persistence of low back pain is thought to be associated with different underlying pain mechanisms, including ongoing nociceptive input and central sensitisation. We hypothesised that primary motor cortex (M1) representations of back muscles (a measure of motor system adaptation) would differ between pain mechanisms, with more consistent observations in individuals presumed to have an ongoing contribution of nociceptive input consistently related to movement/posture. We tested 28 participants with low back pain sub‐grouped by the presumed underlying pain mechanisms: nociceptive pain, nociplastic pain, and a mixed group with features consistent with both. Transcranial magnetic stimulation was used to study M1 organization of back muscles. M1 maps of multifidus (deep & superficial), and longissimus erector spinae were recorded with fine‐wire electromyography and thoracic erector spinae with surface electromyography. The nociplastic pain group had greater variability in M1 map location (centre of gravity) than other groups (p<0.01), which may suggest less consistency, and perhaps relevance, of motor cortex adaptation for that group. The mixed group had greater overlap of M1 representations between deep/superficial muscles than nociceptive pain (deep multifidus/longissimus: p=0.001, deep multifidus/thoracic erector spinae: p=0.008), and nociplastic pain (deep multifidus/longissimus: p=0.02, deep multifidus/thoracic erector spinae: p= 0.02) groups. This study provides preliminary evidence of differences in M1 organisation in subgroups of low back pain classified by likely underlying pain mechanisms. Despite the sample size, differences in cortical re‐organisation between subgroups were detected. Differences in M1 organisation in subgroups of low back pain supports tailoring of treatment based on pain mechanism and motor adaptation.
Article
Patients' beliefs about the origin of their pain and their cognitive processing of pain-related information have both been shown to be associated with poorer prognosis in low back pain (LBP), but the relationship between specific beliefs and specific cognitive processes is not known. The aim of this study was to study the relationship between diagnostic uncertainty and recall bias in two groups of chronic LBP patients, those who were certain about their diagnosis, and those who believed that their pain was due to an undiagnosed problem. Patients (N=68) endorsed and subsequently recalled pain, illness, depression and neutral stimuli. They also provided measures of pain, diagnostic status, mood and disability. Both groups exhibited a recall bias for pain stimuli, but only the group with diagnostic uncertainty additionally displayed a recall bias for illness-related stimuli. This bias remained after controlling for depression and disability. Sensitivity analyses using grouping by diagnosis/explanation received supported these findings. Higher levels of depression and disability were found in the group with diagnostic uncertainty, but levels of pain intensity did not differ between the groups. Although the methodology does not provide information on causality, the results provide evidence for a relationship between diagnostic uncertainty and recall bias for negative health-related stimuli in chronic LBP patients.
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Study design: Numerous authors have attempted to sub-classify low back pain in order that valid homogenous subsets of low back pain presentations might be recognised. This review systematically appraises these papers. Methods: Medline, Embase, Cinahl, AMED and PEDro electronic databases were searched with subsequent hand searching of bibliographies. Papers were included between June 1983 and June 2003. Two reviewers independently reviewed 32 papers using a standard scoring criteria for assessment. A third reviewer mediated disagreements. Results: Thirty-two papers were reviewed, with classification systems being grouped by method of classification. Classification has been attempted by implication of patho-anatomical source, by clinical features, by psychological features, by health and work status and in one case by a biopsychosocial weighting system. Scores were generally higher for systems using a statistical cluster analysis approach to classification than a judgemental approach. Both approaches have specific advantages and disadvantages with a synthesis of both methodologies being most likely to generate an optimal classification system. Conclusions: The classification of NSLBP has traditionally involved the use of one paradigm. In the present era of biopsychosocial management of NSLBP, there is a need for an integrated classification system that will allow rational assessment of NSLBP from biomedical, psychological and social constructs.
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The evidence that exercise intervention is effective for treatment of chronic low back pain comes from trials that are not placebo-controlled. The purpose of this study was to investigate the efficacy of motor control exercise for people with chronic low back pain. This was a randomized, placebo-controlled trial. The study was conducted in an outpatient physical therapy department in Australia. Patients The participants were 154 patients with chronic low back pain of more than 12 weeks' duration. Twelve sessions of motor control exercise (ie, exercises designed to improve function of specific muscles of the low back region and the control of posture and movement) or placebo (ie, detuned ultrasound therapy and detuned short-wave therapy) were conducted over 8 weeks. Primary outcomes were pain intensity, activity (measured by the Patient-Specific Functional Scale), and patient's global impression of recovery measured at 2 months. Secondary outcomes were pain; activity (measured by the Patient-Specific Functional Scale); patient's global impression of recovery measured at 6 and 12 months; activity limitation (measured by the Roland-Morris Disability Questionnaire) at 2, 6, and 12 months; and risk of persistent or recurrent pain at 12 months. The exercise intervention improved activity and patient's global impression of recovery but did not clearly reduce pain at 2 months. The mean effect of exercise on activity (measured by the Patient-Specific Functional Scale) was 1.1 points (95% confidence interval [CI]=0.3 to 1.8), the mean effect on global impression of recovery was 1.5 points (95% CI=0.4 to 2.5), and the mean effect on pain was 0.9 points (95% CI=-0.01 to 1.8), all measured on 11-point scales. Secondary outcomes also favored motor control exercise. Limitation Clinicians could not be blinded to the intervention they provided. Motor control exercise produced short-term improvements in global impression of recovery and activity, but not pain, for people with chronic low back pain. Most of the effects observed in the short term were maintained at the 6- and 12-month follow-ups.
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Unlabelled: Central sensitization represents an enhancement in the function of neurons and circuits in nociceptive pathways caused by increases in membrane excitability and synaptic efficacy as well as to reduced inhibition and is a manifestation of the remarkable plasticity of the somatosensory nervous system in response to activity, inflammation, and neural injury. The net effect of central sensitization is to recruit previously subthreshold synaptic inputs to nociceptive neurons, generating an increased or augmented action potential output: a state of facilitation, potentiation, augmentation, or amplification. Central sensitization is responsible for many of the temporal, spatial, and threshold changes in pain sensibility in acute and chronic clinical pain settings and exemplifies the fundamental contribution of the central nervous system to the generation of pain hypersensitivity. Because central sensitization results from changes in the properties of neurons in the central nervous system, the pain is no longer coupled, as acute nociceptive pain is, to the presence, intensity, or duration of noxious peripheral stimuli. Instead, central sensitization produces pain hypersensitivity by changing the sensory response elicited by normal inputs, including those that usually evoke innocuous sensations. Perspective: In this article, we review the major triggers that initiate and maintain central sensitization in healthy individuals in response to nociceptor input and in patients with inflammatory and neuropathic pain, emphasizing the fundamental contribution and multiple mechanisms of synaptic plasticity caused by changes in the density, nature, and properties of ionotropic and metabotropic glutamate receptors.
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Voluntary lumbopelvic control is compromised in patients with back pain. Loss of proprioceptive acuity is one contributor to decreased control. Several reasons for decreased proprioceptive acuity have been proposed, but the integrity of cortical body maps has been overlooked. We investigated whether tactile acuity, a clear clinical signature of primary sensory cortex organisation, relates to lumbopelvic control in people with back pain. Forty-five patients with back pain and 45 age- and sex-matched healthy controls participated in this cross-sectional study. Tactile acuity at the back was assessed using two-point discrimination (TPD) threshold in vertical and horizontal directions. Voluntary motor control was assessed using an established battery of clinical tests. Patients performed worse on the voluntary lumbopelvic tasks than healthy controls did (p<0.001). TPD threshold was larger in patients (mean (SD)=61 (13) mm) than in healthy controls (44 (10) mm). Moreover, larger TPD threshold was positively related to worse performance on the voluntary lumbopelvic tasks (Pearson's r=0.49; p<0.001). Tactile acuity, a clear clinical signature of primary sensory cortex organisation, relates to voluntary lumbopelvic control. This relationship raises the possibility that the former contributes to the latter, in which case training tactile acuity may aid recovery and assist in achieving normal motor performance after back injury.
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There is a lack of studies examining whether mechanism-based classification systems (CS) acknowledging biological, psychological and social dimensions of long-lasting low back pain (LBP) disorders can be performed in a reliable manner. The purpose of this paper was to examine the inter-tester reliability of clinicians' ability to independently classify patients with non-specific LBP (NSLBP), utilising a mechanism-based classification method. Twenty-six patients with NSLBP underwent an interview and full physical examination by four different physiotherapists. Percentage agreement and Kappa coefficients were calculated for six different levels of decision making. For levels 1-4, percentage agreement had a mean of 96% (range 75-100%). For the primary direction of provocation Kappa and percentage agreement had a mean between the four testers of 0.82 (range 0.66-0.90) and 86% (range 73-92%) respectively. At the final decision making level, the scores for detecting psychosocial influence gave a mean Kappa coefficient of 0.65 (range 0.57-0.74) and 87% (range 85-92%). The findings suggest that the inter-tester reliability of the system is moderate to substantial for a range of patients within the NSLBP population in line with previous research.
Article
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Classification systems for patients with low back pain have become more abundant in the literature since the mid-1980s. Some classification systems are designed to determine the most appropriate treatment, some are designed to aid in prognosis, and others are designed to identify pathology. Still other classification systems categorize patients into homogeneous groups based on selected variables. The purpose of this review is to describe and critically evaluate low back pain classification systems. Several classification systems were summarized and examined. Four classification systems that were judged to be the most commonly cited and most relevant to physical therapists were critiqued using a more thorough systematic approach. The analysis suggests that future research should address the usefulness of existing classification systems as well as the development of new classification systems designed using commonly accepted measurement principles.
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Pain is a unified experience composed of interacting discriminative, affective-motivational, and cognitive components, each of which is mediated and modulated through forebrain mechanisms acting at spinal, brainstem, and cerebral levels. The size of the human forebrain in relation to the spinal cord gives anatomical emphasis to forebrain control over nociceptive processing. Human forebrain pathology can cause pain without the activation of nociceptors. Functional imaging of the normal human brain with positron emission tomography (PET) shows synaptically induced increases in regional cerebral blood flow (rCBF) in several regions specifically during pain. We have examined the variables of gender, type of noxious stimulus, and the origin of nociceptive input as potential determinants of the pattern and intensity of rCBF responses. The structures most consistently activated across genders and during contact heat pain, cold pain, cutaneous laser pain or intramuscular pain were the contralateral insula and anterior cingulate cortex, the bilateral thalamus and premotor cortex, and the cerebellar vermis. These regions are commonly activated in PET studies of pain conducted by other investigators, and the intensity of the brain rCBF response correlates parametrically with perceived pain intensity. To complement the human studies, we developed an animal model for investigating stimulus-induced rCBF responses in the rat. In accord with behavioral measures and the results of human PET, there is a progressive and selective activation of somatosensory and limbic system structures in the brain and brainstem following the subcutaneous injection of formalin. The animal model and human PET studies should be mutually reinforcing and thus facilitate progress in understanding forebrain mechanisms of normal and pathological pain.
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Limb movement imparts a perturbation to the body. The impact of that perturbation is limited via anticipatory postural adjustments. The strategy by which the CNS controls anticipatory postural adjustments of the trunk muscles during limb movement is altered during acute back pain and in people with recurrent back pain, even when they are pain free. The altered postural strategy probably serves to protect the spine in the short term, but it is associated with a cost and is thought to predispose spinal structures to injury in the long term. It is not known why this protective strategy might occur even when people are pain free, but one possibility is that it is caused by the anticipation of back pain. In eight healthy subjects, recordings of intramuscular EMG were made from the trunk muscles during single and repetitive arm movements. Anticipation of experimental back pain and anticipation of experimental elbow pain were elicited by the threat of painful cutaneous stimulation. There was no effect of anticipated experimental elbow pain on postural adjustments. During anticipated experimental back pain, for single arm movements there was delayed activation of the deep trunk muscles and augmentation of at least one superficial trunk muscle. For repetitive arm movements, there was decreased activity and a shift from biphasic to monophasic activation of the deep trunk muscles and increased activity of superficial trunk muscles during anticipation of back pain. In both instances, the changes were consistent with adoption of an altered strategy for postural control and were similar to those observed in patients with recurrent back pain. We conclude that anticipation of experimental back pain evokes a protective postural strategy that stiffens the spine. This protective strategy is associated with compressive cost and is thought to predispose to spinal injury if maintained long term.
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Prospective, cross-sectional observational study. The aim of this study was to determine if there was an association between wasting of psoas and multifidus as observed on MRI scans and the presenting symptoms, reported pathology, pain, or disability of a cohort of patients presenting with unilateral low back pain. Current physiotherapy practice is often based on localized spine stabilizing muscle exercises; most attention has been focused on transversus abdominus and multifidus with relatively little on psoas. Fifty consecutive patients presenting to a back pain triage clinic with unilateral low back pain lasting more than 12 weeks were recruited. The cross-sectional surface area (CSA) of the muscles was measured. Duration of symptoms, rating of pain, self-reported function, and the presence of neural compression were recorded. Data analysis compared the CSA between the symptomatic and asymptomatic sides. There was a statistically significant difference in CSA between the sides (P < 0.001). There was a positive correlation between the percentage decrease in CSA of psoas on the affected side and with the rating of pain (rho = 0.608, P < 0.01), reported nerve root compression (rho = 0.812, P < 0.01), and the duration of symptoms (rho = 0.886, P < 0.01). There was an association between decrease in the CSA of multifidus and duration of symptoms. Atrophy of multifidus has been used as one of the rationales for spine stabilization exercises. The evidence of coexisting atrophy of psoas and multifidus suggests that a future area for study should be selective exercise training of psoas, which is less commonly used in clinical practice.
Article
A literature search identified eight classification systems that subdivide non-specific low back pain. These eight systems were selected on the basis of the following criteria: they were all developed for the purpose of guiding choice of physiotherapeutic treatments, and they were all based on symptoms and clinical tests. A critical appraisal was performed using a systematic approach including evaluation of validity, reliability, feasibility, and generalizability. None of the classification systems fulfilled all of the requirements and none were considered to have included all relevant categories separated in a way suitable for the purpose. Studies concerning reliability and validity were rarely reported. Generally aspects of validity and reliability were only tested for a few of the criteria used for categorizing patients and construct validity and reliability of the classification systems as a whole were not tested. Future studies ought to focus on the evaluation of existing classification systems and/or the development of new ones, which are capable of meeting basic measurement criteria.
Article
The exponential increase in occupational low back pain disability is a problem that is not being addressed adequately in clinical practice. The notion of achieving primary control through ergonomic intervention, based on biomechanics principles, has so far been unhelpful. The traditional secondary prevention strategies of rest and return to restricted work duties are seemingly suboptimal. Biomechanics/ergonomic considerations may be related to the first onset of low back pain, but there is little evidence that secondary control based solely on these principles will influence the risk of recurrence or progression to chronic disability. More promising in this respect are programs that take account of the psychosocial influences surrounding disability. Work organizational issues are clearly important, but so also is the behavior of clinicians. The balance of the available evidence suggests that clinicians generally should adopt a proactive approach to rehabilitation by recommending, whenever possible, early return to normal rather than restricted duties as well as complementary psychosocial advice if the issue of chronic disability is to be successfully tackled.
Article
Study Design: The contribution of transversus abdominis to spinal stabilization was evaluated indirectly in people with and without low back pain using an experimental model identifying the coordination of trunk muscles in response to a disturbance to the spine produced by arm movement. Objectives: To evaluate the temporal sequence of trunk muscle activity associated with arm movement, and to determine if dysfunction of this parameter was present in patients with low back pain. Summary of Background Data: Few studies have evaluated the motor control of trunk muscles or the potential for dysfunction of this system in patients with low back pain. Evaluation of the response of trunk muscles to limb movement provides a suitable model to evaluate this system. Recent evidence indicates that this evaluation should include transversus abdominis. Methods: While standing, 15 patients with low back pain and 15 matched control subjects performed rapid shoulder flexion, abduction, and extension in response to a visual stimulus. Electromyographic activity of the abdominal muscles, lumbar multifidus, and the contralateral deltoid was evaluated using fine‐wire and surface electrodes. Results: Movement in each direction resulted in contraction of trunk muscles before or shortly after the deltoid in control subjects. The transversus abdominis was invariably the first muscle active and was not influenced by movement direction, supporting the hypothesized role of this muscle in spinal stiffness generation. Contraction of transversus abdominis was significantly delayed in patients with low back pain with all movements. Isolated differences were noted in the other muscles. Conclusions: The delayed onset of contraction of transversus abdominis indicates a deficit of motor control and is hypothesized to result in inefficient muscular stabilization of the spine.
Article
When a patient presents himself with the common complaint of pain in the shoulder region and arm, with or without limitation of motion and unrelated to severe trauma, the physician usually thinks of the joints, bursae, tendons or nerves rather than of the shoulder girdle muscles as the primary source of pain. Thus the customary diagnosis in this type of patient is either arthritis, subacromial bursitis, brachial neuritis or radiculitis. The well known chronicity of these symptoms and the variety of therapeutic procedures employed suggest either that the customary methods of treatment are unsatisfactory or that the underlying cause is often overlooked. It is our purpose in this report to discuss the diagnosis of a type of pain in the shoulder and arm which has its origin in the muscles of the back or shoulder girdle and to present the results of an effective method of therapy, namely intramuscular infiltration
Article
A literature search identified eight classification systems that subdivide non-specific low back pain. These eight systems were selected on the basis of the following criteria: they were all developed for the purpose of guiding choice of physiotherapeutic treatments, and they were all based on symptoms and clinical tests. A critical appraisal was performed using a systematic approach including evaluation of validity, reliability, feasibility, and generalizability. None of the classification systems fulfilled all of the requirements and none were considered to have included all relevant categories separated in a way suitable for the purpose. Studies concerning reliability and validity were rarely reported. Generally aspects of validity and reliability were only tested for a few of the criteria used for categorizing patients and construct validity and reliability of the classification systems as a whole were not tested. Future studies ought to focus on the evaluation of existing classification systems and/or the development of new ones, which are capable of meeting basic measurement criteria.
Article
Objectives: The aim of this study was to investigate the role of physical and psychological factors on changes in surface electromyography [sEMG] during static and dynamic activity of the lumbar paraspinal muscles in a group of chronic low back pain [CLBP] patients following a pain management program. Methods: Surface electromyographic recordings of the lumbar paraspinal muscle activity of 36 patients attending a pain management program were made during static and dynamic activity prior to the program and immediately afterwards. A measure of abnormality, the Flexion Relaxation Ratio [FRR] was calculated to observe the effect on the Flexion Relaxation Phenomenon [FRP]. Patients were assessed for current back pain and on a range of physical and psychological variables. Results: There were no significant correlations between current pain or disability and the FRRs. Significant correlations were identified between fear avoidance beliefs and low FRRs prior to the Pain Management Program. Following the program, significant correlations were identified between reductions in fear avoidance beliefs, increases in pain self efficacy beliefs and increased FRRs on movement. No such relationships were observed between sEMG measures and changes in range of movement, pain report or disability. Conclusion: The results of this study suggest that the absence or reduction of the FRP, measured by the FRR, in patients with CLBP is influenced by fear of injury and low self efficacy beliefs and changes in FRRs were independent of the range of motion and pain report in the group studied. Therapists should consider the role of psychological factors in the development and resolution of abnormal recruitment in patients with low back pain.
Article
Cross-sectional study. Comparison of the timing of onset of lateral abdominal muscle activity during rapid arm movements in patients with nonspecific chronic low back pain (cLBP) and back-pain-free controls. Rapid movements of the arm are normally associated with prior activation of trunk-stabilizing muscles in readiness for the impending postural perturbation. Using invasive intramuscular electromyography techniques, studies have shown that this feed-forward function is delayed in some patients with low back pain (LBP). Ultrasound tissue Doppler imaging (TDI) provides an ultrasound method for quantifying muscle activation in a noninvasive manner, allowing investigation of larger groups of patients and controls. Ninety-six individuals participated (48 patients with cLBP and 48 matched LBP-free controls). During rapid shoulder flexion, abduction, and extension, surface electromyographic signals from the deltoid and motion-mode TDI images from the contralateral lateral abdominal muscles were recorded simultaneously. The onset of muscle activity was given by changes in the tissue velocity of the abdominal muscles, as measured with TDI. Pain and disability in the patients were assessed using standardized questionnaires. Data were analyzed using repeated measures analysis of variance. In both groups, feed-forward activity of the lateral abdominal muscles was recorded during arm movements in all directions. The main effect of "group membership" revealed no significant difference between the groups for the earliest onset of abdominal muscle activity (P = 0.398). However, a significant "group x body side" interaction (P = 0.015) was observed, and this was the result of earlier onsets in the cLBP group than controls for the abdominal muscles on the right (but not left) body side. No relationship was found between the time of onset of the earliest abdominal muscle activity and pain intensity, pain frequency, pain medication usage, or Roland Morris disability scores. Patients with cLBP did not show a delayed onset of feed-forward activation of the lateral abdominal muscles during rapid arm movements. Earlier activation was observed for one body side compared with the controls. However, the clinical relevance of this finding remains obscure, especially because there was no relationship between the onset of activation and any clinical parameters.
Article
A preliminary cross-sectional comparative study of adolescents with nonspecific chronic low back pain (NSCLBP) and healthy controls. To investigate whether differences in spinal kinematic and trunk muscle activity exist in both usual and slump sitting in adolescents with NSCLBP. Evidence suggests that low back pain commonly develops in adolescence and increases the risk for low back pain in adulthood. Sitting is an important consideration in adolescents with NSCLBP: currently there are no reports investigating their motor control strategies in sitting. Twenty-eight adolescents (14 female) with NSCLBP and 28 matched pain-free controls were recruited from a large cohort study. Pain subjects were subclassified based on O'Sullivan's classification system. Three-dimensional lumbo-pelvic kinematic data and the activation of 3 back and 2 abdominal muscles were recorded during usual and slump sitting. The flexion-relaxation phenomenon in sitting was also investigated. Spinal posture in usual and slump sitting were similar for adolescents with and without NSCLBP. However, differences were identified in both sitting conditions when those with NSCLPB were subclassified and compared with controls. Muscle activation differences were not consistently identified, with only lower levels of internal oblique activation in usual sitting in NSCLBP compared with pain-free controls showing significance. Flexion relaxation was observed in both iliocostalis and thoracic erector spinae in the NSCLBP group but not controls. This study provides preliminary results. Differences with sitting posture are only seen when adolescents with NSCLBP are classified. Trunk muscle activation is not a sensitive marker for discriminating subgroups of NSCLBP during adolescence.
Article
The objective of the study was to provide a detailed biopsychosocial evaluation of adolescent NSCLBP compared to those without LBP. NSCLBP was described by pain level, duration, levels of disability and kinesiophobia, aggravating factors and functional movements. Each pain subject was sub-classified using the O'Sullivan system. Groups were compared on physical activity levels, sitting posture, trunk extensor and thigh muscle endurance, psychosocial behaviour, depression, family functioning and exposure to stressful life events. Adolescents with NSCLBP reported moderate levels of pain (4.4/10 +/- 1.9), disability (17.9 +/- 10.1%) and fear avoidance beliefs (36.1/68 +/- 7.1). Differences between control and pain groups were only found for back muscle (p = 0.033) and squat endurance times (p = 0.032) and stressful life events (p = 0.030). Differences in sitting posture between pain and no pain groups were only found when pain subjects were sub-classified (lumbar angle p = 0.001). In conclusion, adolescents with NSCLBP reported moderate pain and disability with deficits in trunk and squat endurance. That they remained physically active is at odds with the activity avoidance and subsequent deconditioning model proposed for adults with NSCLBP. Differences between control and pain groups on history of stressful life events suggest this may contribute to adolescent NSCLBP. Differences with sitting posture are only seen when patients were sub-classified.
Article
Statistical Classification Model for nonspecific chronic low back pain (NS-CLBP) patients and controls based on parameters of motor control. Develop a Statistical Classification Model to discriminate between 2 subgroups of NS-CLBP (Flexion Pattern [FP] and Active Extension Pattern [AEP]) and a control group using biomechanical variables quantifying parameters of motor control. It has been well documented that many CLBP patients have motor control impairments of their lumbar spine. O'Sullivan proposed a mechanism-based classification system for NS-CLBP with motor control impairments based on a comprehensive subjective and physical examination to establish the relationship between pain provocation and spinal motor control. For the FP and AEP s, 2 groups defined by O'Sullivan and under investigation is this study, the motor control impairment is considered to be the mechanism maintaining their CLBP. No previous studies have used a Statistical Model with measurements of motor control impairment to subclassify NS-CLBP patients. Thirty-three NS-CLBP patients (20 FP and 13 AEP) and 34 asymptomatic subjects had synchronized lumbosacral kinematics and trunk muscle activation recorded during commonly reported aggravating postures and movements. Biomechanical variables were quantified and a Statistical Classification Model was developed. The Statistical Model used 5 kinematic and 2 electromyography variables. The model correctly classified 96.4% of cases. Selected biomechanical variables were predictors for subgroup membership and were able to discriminate the 3 subgroups. This study adds further support toward the validation of the proposed classification system.
Article
This study examined the role of pain catastrophizing, fear of movement and depression as determinants of repetition-induced summation of activity-related pain. The sample consisted of 90 (44 women and 46 men) work-disabled individuals with chronic low back pain. Participants were asked to lift a series of 18 canisters that varied according to weight (2.9kg, 3.4kg, 3.9kg) and distance from the body. The canisters were arranged in a 3x6 matrix and the weights were distributed such that each 'column' of three canisters was equated in terms of physical demands. Participants rated their pain after each lift, and in a separate trial, estimated the weight of each canister. Mean activity-related pain ratings were computed for each Column of the task. An index of repetition-induced summation of pain was derived as the change in pain ratings across the six 'columns' of the task. Pain catastrophizing, fear of movement and depression were significantly correlated with condition-related pain (e.g., MPQ) and activity-related pain ratings. Women rated their pain as more intense than men, and estimated weights to be greater than men. A repetition-induced summation of pain effect was observed where pain ratings increased as participants lifted successive canisters. Fear of movement, but not pain catastrophizing or depression, was associated with greater repetition-induced summation of pain. The findings point to possible neurophysiological mechanisms that could help explain why fear of pain is a robust predictor of pain-related disability. Mechanisms of repetition-induced summation of activity-related pain are discussed.
Article
The conscious sense of our body, or body image, is often taken for granted, but it is disrupted in many clinical states including complex regional pain syndrome and phantom limb pain. Is the same true for chronic back pain? Body image was assessed, via participant drawings, in six patients with chronic back pain and ten healthy controls. Tactile threshold and two-point discrimination threshold (TPD) were assessed in detail. All the patients, and none of the controls, showed disrupted body image of the back. Five patients were unable to clearly delineate the outline of their trunk and stated that they could not "find it". TPD was greatly increased in the same zone as the absence or disruption of body image, but was otherwise similar to controls. The disturbance of body image and decrease in tactile acuity coincided with the normal distribution of pain, although there was no allodynia and there was no relationship between resting pain level and TPD. Tactile threshold was unremarkable for patients and controls. These preliminary data indicate that body image is disrupted, and tactile acuity is decreased, in the area of usual pain, in patients with chronic back pain. This finding raises the possibility that training body image or tactile acuity may help patients in chronic spinal pain, as it has been shown to do in patients with complex regional pain syndrome or phantom limb pain.
Article
A prospective study of the sagittal standing posture of 766 adolescents. To determine whether posture subgroups based on photographic assessment are similar to those used clinically and to previous, radiographically determined subgroups of sagittal standing posture, and whether identified subgroups are associated with measures of spinal pain. Relatively little research has been performed toward a classification of subjects according to sagittal spinal alignment. Clinical descriptions of different standing posture classifications have been reported, and recently confirmed in a radiographic study. There is limited epidemiological data available to support the belief that specific standing postures are associated with back pain, despite plausible mechanisms. As posture assessment using radiographic methods are limited in large population studies, successful characterization of posture using 2-dimensional photographic images will enable epidemiological research of the association between posture types and spinal pain. METHODS.: Three angular measures of thoraco-lumbo-pelvic alignment were calculated from lateral standing photographs of subjects with retro-reflective markers placed on bony landmarks. Subgroups of sagittal thoracolumbar posture were determined by cluster analysis of these 3 angular measures. Back pain experience was assessed by questionnaire. The associations between posture subgroups and spinal pain variables were evaluated using logistic regression. Postural subtypes identified by cluster analysis closely corresponded to those subtypes identified previously by analysis of radiographic spinal images in adults and to those described clinically. Significant associations between posture subgroups and weight, height, body mass index, and gender were identified. Those adolescents classified as having non-neutral postures when compared with those classified as having a neutral posture demonstrated higher odds for all measures of back pain, with 7 of 15 analyses being statistically significant. Meaningful classifications exist for adolescent sagittal thoraco-lumbo-pelvic alignment, and these can be determined successfully from sagittal photographs. More neutral thoraco-lumbo-pelvic postures are associated with less back pain.
Article
Two cases of low back pain from quadratus lumborum myofascial trigger points are presented. One of the patients suffered from an acute episode while the other had a chronic condition. This condition may be more common than previously believed. The quadratus lumborum should be examined in patients presenting with flank pain as well as low back, buttock and lateral hip pain. Thoracolumbar joint dysfunction may often coexist with quadratus lumborum myofascitis and must be treated for optimal results. Myofascial therapy directed at restoring muscle length and function, coupled with joint manipulation to related dysfunctional areas, was implemented. Diagnosis and treatment are outlined.
Article
Most patients with low back pain experience loss of spinal and hip extension range of motion. The limitation appears to involve significant iliopsoas myofascial dysfunction manifested in tenderness, as shown by deep abdominal palpation of the psoas muscle, hip flexor contracture, pain elicited by the stretch maneuver of the spine and hip, and relative weakness of the psoas muscle when tested manually. These signs assisted in identifying the source of low back pain in six patients who had failed to respond to prior treatment. Therapy consisted of iliopsoas trigger point treatment using a dry needling technique, followed by self-administered postisometric relaxation exercise of the iliopsoas. In all cases, marked improvement of hip and spine extension, dramatic reduction of pain, and return to normal activity resulted. Given the low risk-to-benefit ratio, trigger point treatment is indicated in "failed back syndrome" and chronic low back pain after conservative therapy or surgery have been tried without success.
Article
A prospective survey of patients seeking primary care for low back pain. Clinical and psychosocial data, available at presentation, were explored for predictors of outcome at 1 year. To determine the relative value of clinical and psychosocial variables for early identification of patients with a poor prognosis. Current treatment strategies for low back pain have failed to stem the rising levels of disability. Psychosocial factors have been shown to be important determinants of response to therapy in chronic patients, but the contribution from similar data in acute or subchronic patients has not been comprehensively investigated. Two hundred fifty-two patients with low back pain, presenting to primary care, underwent a structured clinical interview and completed a battery of psychosocial instruments. Follow-up was done by mail at 1 year; outcome was measured using a back pain disability questionnaire. Predictive relationships were sought between the data at presentation and disability at follow-up. Most patients showed improved disability and pain scores, although more than half had persisting symptoms. Eighteen percent showed significant psychological distress at presentation. Multiple regression analysis showed the level of persisting disability to depend principally on measures in the psychosocial domain; for acute cases outcome is also dependent on the absence or presence of a previous history of low back trouble. Discriminant models successfully allocated typically 76% of cases to recovered/not-recovered groups, largely on the basis of psychosocial factors evident at presentation. Early identification of psychosocial problems is important in understanding, and hopefully preventing, the progression to chronicity in low back trouble.
Article
A database for estimated normal spinal motion was derived using a noninvasive, high-resolution, computer-aided system, which tracks the motion of skin markers strategically placed on the spine. Forty normal subjects, selected from hundreds of possible subjects according to rigorous inclusion/exclusion criteria, were tested on the system. Patterns of estimated spinal motion were analyzed as a function of load, age, and sex, confirming a correlation between the movement of spinal segments and the motion of skin markers. The Workers Compensation Board of Quebec funded and supervised the experiments necessary to establish a normative reference database for a high-resolution motion analysis system that permits a noninvasive assessment of spinal function. A previous study examined the correlation between the movements of the skin markers and the underlying bony structures for trunk flexion. Skin movement cannot be random and contains information characterizing both the spine and its surrounding soft tissues. A noninvasive dynamic imaging system was used to measure normal spinal function under free movement. A high-resolution three-dimensional camera system collected basic kinematic data from strategically placed skin markers over the lumbar spine while the activity of paraspinal muscles was being recorded with surface electromyography. The measurements were analyzed for consistent, specific patterns recognizable as normal lumbar spine skin motion and reflecting normal lumbar spine function. A comparison was made with previous radiographic studies to confirm the correlation between the motion of skin markers and lumbar spine function. Lumbar skin marker motion patterns in normal subjects were consistent and varied little with load; gender had no effect except in the initial phase of a movement. There was less mobility but similar coordination in older subjects. No inconsistencies with previous radiologic investigations were found for sagittal and lateral plane movement.
Article
This study tested the possibility of obtaining the activity of deeper muscles in the torso—specifically psoas, quadratus lumborum, external oblique, internal oblique and transverse abdominis, using surfce myoelectric electrodes. It was hypothesized that: (1) surface electrodes adequately represent the amplitude of deep muscles (specifically psoas, quadratus lumborum, external oblique, internal oblique, transverse abdominis); (2) a single surface electrode location would best represent the activation profiles of each deep muscle over a broad variety of tasks. We assumed that prediction of activation within 10% of maximum voluntary contraction (RMS difference between the surface and intramuscular channels), over the time history of the signal, was reasonable and acceptable to assist clinical interpretation of muscle activation amplitude, and ultimately for modeled estimates of muscle force. Surface electrodes were applied and intramuscular electrodes were inserted on the left side of the body in five men and three women who then performed a wide variety of flexor tasks (bent knee and straight leg situps and leg raises, curl ups), extensor tasks (including lifting barbells up to 70 kg), lateral bending tasks (standing lateral bend and horizontal lying side support), twisting tasks (standing and sitting), and internal/external hip rotation. Using the criteria of RMS difference and the coefficient of determination (R²) to compare surface with intramuscular myoelectric signals, the results indicated that selected surface electrodes adequately represent the amplitude of deep muscles—always within 15% RMS difference, or less with the exception of psoas where differences up to 20% were observed but only in certain maximum voluntary contraction efforts.
Article
The contribution of transversus abdominis to spinal stabilization was evaluated indirectly in people with and without low back pain using an experimental model identifying the coordination of trunk muscles in response to a disturbances to the spine produced by arm movement. To evaluate the temporal sequence of trunk muscle activity associated with arm movement, and to determine if dysfunction of this parameter was present in patients with low back pain. Few studies have evaluated the motor control of trunk muscles or the potential for dysfunction of this system in patients with low back pain. Evaluation of the response of trunk muscles to limb movement provides a suitable model to evaluate this system. Recent evidence indicates that this evaluation should include transversus abdominis. While standing, 15 patients with low back pain and 15 matched control subjects performed rapid shoulder flexion, abduction, and extension in response to a visual stimulus. Electromyographic activity of the abdominal muscles, lumbar multifidus, and the surface electrodes. Movement in each direction resulted in contraction of trunk muscles before or shortly after the deltoid in control subjects. The transversus abdominis was invariably the first muscle active and was not influenced by movement direction, supporting the hypothesized role of this muscle in spinal stiffness generation. Contraction of transversus abdominis was significantly delayed in patients with low back pain with all movements. Isolated differences were noted in the other muscles. The delayed onset of contraction of transversus abdominis indicates a deficit of motor control and is hypothesized to result in inefficient muscular stabilization of the spine.