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Classification of lumbopelvic pain disorders - Why is it essential for management

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... One of these classification systems is the Multidimensional Classification System (MDCS) [24]. The MDCS outlines five motor control impairment (MCI) subgroups with the flexion pattern (FP) and active extension pattern (AEP) being the most common in the clinical setting [25,26]. Based on O'Sullivan [24], MCI subgroups exhibit full range of motion (ROM) in the direction of pain provocation. ...
... AEP and FP were chosen in this study because of their high prevalence [25,26]. To establish MCI subgroups classification (AEP and FP), comprehensive subjective and objective assessments were conducted. ...
... Reaching in the PM direction requires anterior pelvic tilt and stresses lumbar spine resulting in excessive lordosis or hyperextension of lumbar spine. Based on the MCI classification, the standing and extension positions are more likely to aggravate pain in the AEP group as compared to the FP group [26]. According to the pain adaptation model, the normal response of the body is to increase paraspinal muscle activity in the AEP subjects, which may increase the load on the trunk structure [46]. ...
... Sheeran et al. [9] also used a three-dimensional kinematics motion capture system to assess spinal and pelvic kinematics during sitting and standing activities in healthy and LBP patients. O'Sullivan et al. [10] introduced a multi-dimensional classification system (MDCS) to stratify patients based on movement and pain-based subsets (flexion pattern (FP), active extension pattern (AEP) and passive extension pattern (PEP)). Based on the novel Cardiff Classifier method, they were able to discriminate between different LBP subgroups with an accuracy of 96.8%, 87.7% and 70.27% for FP from PEP, FP from AEP and AEP from PEP subtypes, respectively. ...
... Contrary to the study of Sheeran et al. [9], which requires a well-equipped laboratory space, the portable wearable inertial sensors and protocol presented here, can be easily applied in clinical settings. Furthermore, using the STarT questionnaire, unlike other subgrouping methods of LBP patients such as O'Sullivan [10], does not require any specific expertise and can be easily integrated in modern clinical practice. Moreover, flexion/extension tasks are among the simplest possible movements that a patient can safely perform under supervision. ...
... In the present study, the pain score was not significantly different among the subgroups of patients during testing. Subgrouping in the O'Sullivan approach was performed by an expert clinician through examining the lumbar range of motion during active and passive flexion/extension, as long as the patient feels pain [10]. Therefore, it can be postulated that pain is an important factor for distinguishing patients, as it directly affects classification and should not be eliminated from assessment protocols. ...
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The successful clinical application of patient-specific personalized medicine for the management of low back patients remains elusive. This study aimed to classify chronic nonspecific low back pain (NSLBP) patients using our previously developed and validated wearable inertial sensor (SHARIF-HMIS) for the assessment of trunk kinematic parameters. One hundred NSLBP patients consented to perform repetitive flexural movements in five different planes of motion (PLM): 0 • in the sagittal plane, as well as 15 • and 30 • lateral rotation to the right and left, respectively. They were divided into three subgroups based on the STarT Back Screening Tool. The sensor was placed on the trunk of each patient. An ANOVA mixed model was conducted on the maximum and average angular velocity, linear acceleration and maximum jerk, respectively. The effect of the three-way interaction of Subgroup by direction by PLM on the mean trunk acceleration was significant. Subgrouping by STarT had no main effect on the kinematic indices in the sagittal plane, although significant effects were observed in the asymmetric directions. A significant difference was also identified during pre-rotation in the transverse plane, where the velocity and acceleration decreased while the jerk increased with increasing asymmetry. The acceleration during trunk flexion was significantly higher than that during extension, in contrast to the velocity, which was higher in extension. A Linear Discriminant Analysis, utilized for classification purposes, demonstrated that 51% of the total performance classifying the three STarT subgroups (65% for high risk) occurred at a position of 15 • of rotation to the right during extension. Greater discrimination (67%) was obtained in the classification of the high risk vs. low-medium risk. This study provided a smart "sensor-based" practical methodology for quantitatively assessing and classifying NSLBP patients in clinical settings. The outcomes may also be utilized by leveraging cost-effective inertial sensors, already available in today’s smartphones, as objective tools for various health applications towards personalized precision medicine.
... Although information on pain location, change in pain in response to movement and regional hypo/hypermobility were recorded, no distinct clusters of these signs and symptoms were evident. These clinical features have been advocated as important responses in the subclassification of NSLBP by previous authors (Fritz et al., 2000;Werneke and Hart, 2001;Van Dillen et al., 2003;O'Sullivan, 2006;O'Sullivan and Beales, 2007a;O'Sullivan and Beales, 2007b); however, this method did not replicate any subgroups described previously. This may have been due to a lack of sensitivity of the cluster analysis, particularly in a model with a large number of variables in relation to the number of subjects. ...
... The vast majority of data collected were of physical impairment. Very few data were collected that reflected functional disability, and thus this classification approach has more in common with classification systems using movement and pain response to classify NSLBP (Peterson et al., 1999;Fritz et al., 2003;Van Dillen et al., 2003;Laslett et al., 2005: O'Sullivan, 2006 than those classifying by physical activity and perceptions of pain (Hill et al., 2008;Hill et al., 2010). These differing approaches to classification probably reflect the wide-ranging requirements of diagnostic classification systems applied to a condition that affects each domain of the biopsychosocial domains. ...
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Non-specific low back pain (NSLBP) accounts for over 85% of all low back pain. Homogenous subgroups may exist within this diagnosis. This study derived a clinical examination and evaluated the examination's ability to identify homogenous subgroups in NSLBP. Patients with NSLBP were examined using a standardized clinical examination. Each patient was examined by two physiotherapists. Data were analysed for item reliability and the presence of distinct subgroups using cluster analysis. Cross-validation of the clusters identified was conducted. Three hundred and one patients were examined. The inter-tester reliability of the majority of items was moderate to substantial (52% of items with kappa > 0.40). A K-means cluster analysis of the two data sets revealed agreement on the presence of two subgroups. One group (n = 47, 16%) had higher fear avoidance beliefs, anxiety and disability. They were more likely to be provoked by pain provocative tests. They were also more likely to be judged as having central sensitization and a dominant psychosocial component to their presentation. The identification of a group of hypervigilant NSLBP patients should allow the interventions to be targeted towards this group. A valid, standardized clinical examination does contribute to the diagnostic management of NSLBP.
... Recently, different classifications have been presented for LBP. One of these classifications is called the Multi-Dimensional Classification System (MDCS) which has been presented in 2006 by O'Sullivan [4]. According to the MDCS, the condition has been sorted according to the direction of the most painful movement into flexion, extension, or global LBP. ...
... Permuted blocks with variable sizes [4,6] were used to randomly allocate the participants into either the SNAG or Sham Group. The allocation ratio was 1:1. ...
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Background: Low back pain (LBP) is a common musculoskeletal problem, which commonly affects balance. Sustained natural apophyseal glide (SNAG) is a successful treatment approach for LPB. However, its influence on balance problems has not been studied before. Objective: To investigate the immediate effect of SNAG on postural stability and pain in individuals with flexion-dominant chronic low back pain (FCLBP). Methods: Randomized placebo-controlled trial in which 64 participants with FCLBP were randomly allocated into two groups (SNAG and sham). SNAG group (n= 32) received central lumbar SNAG on the symptomatic lumbar level(s). Sham group (n= 32) received sham SNAG. The outcome measures were postural stability indices; overall stability index (OSI), anteroposterior stability index (APSI), and mediolateral stability index (MLSI) in addition to pain intensity. Outcomes were assessed using the Biodex Balance System and visual analog scale respectively. Measures were taken before and immediately after interventions. Results: There were statistical significance and high effect size (ES) in favor of the SNAG group regarding OSI, APSI, and pain (p> 0.01, cohen's d ES =1.3, 1.4, 1.1 respectively). MLSI showed moderate ES (cohen's d= 0.7) but did not reach a statistically significant level (p= 0.05). Conclusion: Lumbar SNAG produces an immediate improvement in postural stability and pain in subjects with FCLBP.
... Clinical classification models such as the multi-dimensional classification system (MDCS) (O'Sullivan, 2006), that subgroup NSLBP into distinct subsets on the basis of posture and movement pain behaviour, can be utilised to help in clinical decision making when individualising exercise programmes. These clinical subsets have demonstrated consistent, distinct differences in spinal and pelvic kinematics during https://doi.org/10.1016/j.clinbiomech.2019.10.004 ...
... Assessment of motor function forms an important part of the clinical classification process (O'Sullivan, 2006). This was corroborated by biomechanical investigations identifying that compared to no-LBP, flexion pattern individuals sit and move nearer the end-range of lumbar flexion whilst extension pattern individuals tend to operate with their lumbar spine in relative extension (Astfalck et al., 2010;Dankaerts et al., 2006a;Hemming et al., 2018;O'Sullivan et al., 2013;Sheeran et al., 2012). ...
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Background: Low back pain (LBP) classification systems are used to deliver targeted treatments matched to an individual profile, however, distinguishing between different subsets of LBP remains a clinical challenge. Methods: A novel application of the Cardiff Dempster-Shafer Theory Classifier was employed to identify clinical subgroups of LBP on the basis of repositioning accuracy for subjects performing a sitting and standing posture task. 87 LBP subjects, clinically subclassified into flexion (n = 50), passive extension (n = 14), and active extension (n = 23) motor control impairment subgroups and 31 subjects with no LBP were recruited. Thoracic, lumbar and pelvic repositioning errors were quantified. The Classifier then transformed the error variables from each subject into a set of three belief values: (i) consistent with no LBP, (ii) consistent with LBP, (iii) indicating either LBP or no LBP. Findings: In discriminating LBP from no LBP the Classifier accuracy was 96.61%. From no-LBP, subsets of flexion LBP, active extension and passive extension achieved 93.83, 98.15% and 97.62% accuracy, respectively. Classification accuracies of 96.8%, 87.7% and 70.27% were found when discriminating flexion from passive extension, flexion from active extension and active from passive extension subsets, respectively. Sitting lumbar error magnitude best discriminated LBP from no LBP (92.4% accuracy) and the flexion subset from no-LBP (90.1% accuracy). Standing lumbar error best discriminated active and passive extension from no LBP (94.4% and 95.2% accuracy, respectively). Interpretation: Using repositioning accuracy, the Cardiff Dempster-Shafer Theory Classifier distinguishes between subsets of LBP and could assist decision making for targeted exercise in LBP management.
... 9 Musculoskeletal complaints among computer workers have a multifactorial etiology, 5,10 and the main causes include poor postures, bad habits at work, workstation design, and psychosocial factors. 5 Among these multiple factors, biomechanical (postures, changes in body scheme, protective muscle patterns, and physical unfitness) 11 and lifestyle (sedentary behavior, inactivity, and sleep debts) characteristics are noteworthy. 12 In the field of ergonomics, the most used method to investigate the influence of biomechanical, ergonomic, and psychosocial variables on musculoskeletal disorders is based on self-reporting of symptoms. ...
Article
Introduction: Information technologies have become indispensable in the office environment with a considerable increase in the use of computers. Musculoskeletal complaints in computer workers have a multifactorial etiology; therefore, an ergonomic investigation should be based on both self-reporting of symptoms and quantifiable observational methods. Objectives: This study aimed to evaluate ergonomic and biomechanical characteristics of computer workers to identify the presence of symptoms and to assess the existence of a correlation between experts' observational assessment and workers' self-perception. Methods: Participants were approached by an observer responsible for screening of symptoms and demographic characteristics. Volunteers were then evaluated simultaneously by two blinded observers. Results: Seventy-one computer workers participated, and no significant differences were observed for duration of work on a computer between participants with and without pain. Interobserver reliability was good (0.93, 95%CI 0.88-0.96). No correlation was found between Maastricht Upper Extremity Questionnaire and Rapid Office Strain Assessment scores (p = 0.054/r = 0.230). There was no difference between participants with and without pain in the Rapid Office Strain Assessment (p = 0.931). In the Maastricht Upper Extremity Questionnaire assessment, there were differences in job demand (p = 0.004), complaints (p = 0.034), and total score (p = 0.044), with higher scores for asymptomatic participants. Conclusions: The results suggest that asymptomatic individuals are subject to higher job demands probably because they have not previously experienced significant pain. However, they have other complaints, such as stiffness, disability, weakness, edema, and paresthesia. Symptomatic individuals, in turn, have greater trouble in aspects such as reduced amount of time spent on work and performance of work requiring extra effort.
... However, most clinicians [3,4] and researchers [3] believe NSLBP to be a number of conditions, and subgrouping NSLBP is currently of clinical and research interest [5][6][7][8][9][10]. This interest is premised on the notion that patient outcomes might be improved with more precise targeting of treatment, and health system efficiency might be improved with more effective triage of patients. ...
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There is considerable clinician and researcher interest in whether the outcomes for patients with low back pain, and the efficiency of the health systems that treat them, can be improved by 'subgrouping research'. Subgrouping research seeks to identify subgroups of people who have clinically important distinctions in their treatment needs or prognoses. Due to a proliferation of research methods and variability in how subgrouping results are interpreted, it is timely to open discussion regarding a conceptual framework for the research designs and statistical methods available for subgrouping studies (a method framework). The aims of this debate article are: (1) to present a method framework to inform the design and evaluation of subgrouping research in low back pain, (2) to describe method options when investigating prognostic effects or subgroup treatment effects, and (3) to discuss the strengths and limitations of research methods suitable for the hypothesis-setting phase of subgroup studies. The proposed method framework proposes six phases for studies of subgroups: studies of assessment methods, hypothesis-setting studies, hypothesis-testing studies, narrow validation studies, broad validation studies, and impact analysis studies. This framework extends and relabels a classification system previously proposed by McGinn et al (2000) as suitable for studies of clinical prediction rules. This extended classification, and its descriptive terms, explicitly anchor research findings to the type of evidence each provides. The inclusive nature of the framework invites appropriate consideration of the results of diverse research designs. Method pathways are described for studies designed to test and quantify prognostic effects or subgroup treatment effects, and examples are discussed. The proposed method framework is presented as a roadmap for conversation amongst researchers and clinicians who plan, stage and perform subgrouping research. This article proposes a research method framework for studies of subgroups in low back pain. Research designs and statistical methods appropriate for sequential phases in this research are discussed, with an emphasis on those suitable for hypothesis-setting studies of subgroups of people seeking care.
... Predictably we can expect symptoms to differentially occur in both groups over time. O'Sullivan (2005O'Sullivan ( , 2006 proposes three broad clinical subgroups of CLBP patients, based on the mechanism underlying the disorder. Within one of these groups he proposes an underlying defective motor control problem-primarily as either movement impairments or control impairments. ...
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An integrative functional model largely based upon the observation and analysis of the more common features of neuromusculoskeletal dysfunction encountered in clinical practice was presented as a working hypothesis in Part 1. The functional inter relationships between these regional and general features and their contribution to the development and perpetuation of local and or referred spinal pain syndromes was explored. Here we look more closely at clinical patterns of presentation. A simple classification system of clinical subgroups with back pain and related disorders is offered. These more commonly observed dysfunctional postural and movement strategies have been distilled into a number of dysfunction syndromes which will have predictable consequences. In beginning to provide a map of the tendencies towards, or actual, changed postural and movement responses seen in people with spinal pain and related disorders, this model provides a valuable reference for those working in the body work and movement therapies realm. It is a practical and useful clinical tool to assist diagnosis and help better understand the development and perpetuation of most spinal pain and related disorders. In so doing, more rational, functional and effective therapeutic and research interventions can ensue.
... The recognition of underlying motor control impairments and the need for a related classification system of clinical subgroups with back pain has been advocated by Sahrmann (2001Sahrmann ( , 2002, O'Sullivan (2005O'Sullivan ( , 2006 and Dankaerts et al. (2006a). ...
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An integrative functional model largely based upon clinical observation and analysis of the more common features of neuromusculoskeletal-dysfunction encountered in clinical practice is presented as a working hypothesis in Part 1. This endeavours to incorporate contemporary knowledge and practice. The enlightened work of Professor Vladimir Janda has undoubtedly been seminal in the development of this model; however a further evolution of his work is elaborated on in this paper. Thinkers from the human potential movement as well as the scientific community have provided further valuable insights to assist our understanding of function. A related simple classification system of two main clinical subgroups with back pain and related disorders is offered in Part 2. These are based upon the most usual dysfunctional postural and movement strategies. Further distillation provides a number of dysfunction syndromes which will have predictable consequences. This is not a mathematical, computer generated or theoretical biomechanical model. This model describes ‘what it is’ that we see in our patients, and endeavours to be an overview of the movement related causes of back pain. It provides a clinically useful and practical framework to assist the practitioner in diagnosis and to better understand the development and perpetuation of most spinal pain and related disorders. In so doing, more rational, functional and effective manual and exercise therapy interventions can ensue.
... The concept of non-specific musculoskeletal pain and subgrouping patients based on specific inclusion criteria is well established in the field of low back pain. [10][11][12]33,34 McKenzie and May 13 proposed the idea of subgrouping patients with non-specific shoulder pain based on distinct inclusion criteria into one of the three mechanical syndromes: derangement, dysfunction, or posture syndrome. Classification is based on response to repeated end-range movements and not on pathoanatomical diagnosis. ...
Article
This case report describes the effectiveness of mechanical diagnosis and therapy (MDT) in the management of a patient referred with a diagnosis of shoulder tendonitis. The patient was a 56-year-old male with a 3-month history of left anterior shoulder pain. Upon initial assessment, he presented with a positive open-can test, lift-off test, and Hawkins-Kennedy impingement test. A MDT assessment quickly ruled out cervical involvement and identified a loss of end-range shoulder mobility and pain during active shoulder movement. After the patient underwent a repeated movement examination and treatment based on responses to end-range movements over three visits, his shoulder pain was abolished and motion was fully restored. Despite having positive rotator cuff and impingement signs, this patient was effectively treated with repeated end-range movements over a short period of 2 weeks. This case demonstrates that treatment based on MDT sub-classification principles may be an effective way to manage shoulder pain as it is in the spine.
... Each year 6e9% of adults consult their GPs about back pain (Dunn and Croft, 2006;Jordan et al., 2010) which in the majority of cases is non-specific (NSLBP) (Waddell, 2004). Most available treatments have low to moderate short lasting benefits (Pransky et al., 2010;Patel et al., 2013), suggested to result from the NSLBP heterogeneity and variable treatment response (O'Sullivan, 2006). Identification of subgroups to better target care and maximize treatment potential is a pressing research priority (Costa et al., 2013) and was a key research recommendation in a recent National Institute of Clinical Excellence (NICE) Guideline for Early Management of Persistent Non-Specific Low Back Pain (Savigny et al., 2009). ...
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Classification of non-specific low back pain (NSLBP) was recommended to better target care and so maximise treatment potential. This study investigated physiotherapy practitioners' (PPs) and managers' (PMs) views, experiences and perceptions of barriers and enablers for using classification systems (CSs) to better target treatment for NSLBP in the NHS primary care setting.DesignQualitative focus group and interviews.Methods Data from semi-structured interviews of three PMs and a focus group with five PPs, considered local opinion leaders in physiotherapy, was thematically analysed.ResultsFive themes emerged (i) CS knowledge: PPs and PMs were aware of CSs and agreed with its usefulness. PPs were mostly aware of CSs informing specific treatments whilst PMs were aware of prognosis based CSs. (ii) Using CSs: PPs classify by experience and clinical reasoning skills, shifting between multiple CSs. PMs were confident that evidence-based practice takes place but believed CSs may not be always used. (iii) Advantages/disadvantages of CSs: Effective targeting of treatments to patients was perceived as advantageous; but the amount of training required was perceived as disadvantageous. (iv) Barriers: Patients' expectations, clinicians' perceptions, insufficiently complex CSs, lack of training resources. (v) Enablers: Development of sufficiently complex CSs, placed within the clinical reasoning process, mentoring, positive engagement with stakeholders and patients.ConclusionsPPs and PMs were aware of CSs and agreed with its usefulness. The current classification process was perceived to be largely influenced by individual practitioner knowledge and clinical reasoning skills rather than being based on one CS alone. Barriers and enablers were identified for future research.
... Classification systems for chronic LBP have been criticized as they don't consider the multiple and interacting dimensions (i.e., psychological or movement dimensions) involved in the lived experience of people with LBP (89). Given the variety of classification systems currently available for LBP (90)(91)(92)(93)(94), one might argue that the last thing we need is another one. However, the present classification system for differentiating neuropathic, nociceptive, and CS LBP builds on the available "pain-mechanism based classification" system for LBP (23,24,38) and the classification criteria for CS pain (27). ...
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Low back pain (LBP) is a heterogeneous disorder including patients with dominant nociceptive (e.g., myofascial low back pain), neuropathic (e.g., lumbar radiculopathy), and central sensitization pain. In order to select an effective and preferably also efficient treatment in daily clinical practice, LBP patients should be classified clinically as either predominantly nociceptive, neuropathic, or central sensitization pain. To explain how clinicians can differentiate between nociceptive, neuropathic, and central sensitization pain in patients with LBP. Narrative review and expert opinion SETTING: Universities, university hospitals and private practices METHODS: Recently, a clinical method for the classification of central sensitization pain versus neuropathic and nociceptive pain was developed. It is based on a body of evidence of original research papers and expert opinion of 18 pain experts from 7 different countries. Here we apply this classification algorithm to the LBP population. The first step implies examining the presence of neuropathic low back pain. Next, the differential diagnosis between predominant nociceptive and central sensitization pain is done using a clinical algorithm. The classification criteria are substantiated by several original research findings including a Delphi survey, a study of a large group of LBP patients, and validation studies of the Central Sensitization Inventory. Nevertheless, these criteria require validation in clinical settings. The pain classification system for LBP should be an addition to available classification systems and diagnostic procedures for LBP, as it is focussed on pain mechanisms solely. Chronic pain, neuroscience, diagnosis, clinical reasoning, examination, assessment.
... Irreducible or non-reducible discogenic pain (NRDP) is a proposed subgroup where the clinical features of discogenic pain are present, but in the absence of a positive response to MLS [7,8,[13][14][15]. It has been hypothesised that NRDP may not respond positively to MLS because of inflammatory processes in the disrupted annulus fibrosis [8,[14][15][16][17], chemical sensitisation of the disc [7], an incompetent annulus and resultant non-functional hydrostatic mechanism [8,18], or variation in the direction of nuclear migration during application of MLS [19,20]. There do not appear to be any randomised controlled trials that have investigated the effectiveness of conservative treatments for people with NRDP. ...
Article
Objectives: To evaluate the effectiveness of individualised functional restoration plus guideline-based advice compared to advice alone in people with non-reducible discogenic pain (NRDP). Design: Subgroup analysis within a multicentre, parallel group randomised controlled trial. Setting: Fifteen primary care physiotherapy clinics. Participants: Ninety-six participants with clinical features indicative of NRDP (6 week to 6 month duration of injury). Interventions: Over a 10 week period physiotherapists provided 10 sessions of individualised functional restoration plus guideline-based advice or two sessions of advice alone MAIN OUTCOME MEASURES: Primary outcomes were back and leg pain (separate numerical rating scales) and activity limitation (Oswestry Disability Index). Results: Between-group differences favoured individualised functional restoration over advice for back pain (1.1, 95% CI 0.1 to 2.1), leg pain (1.5, 95% CI 0.4 to 2.6) and Oswestry (6.3, 95% CI 1.3 to 11.4) at 10 weeks as well as Oswestry at 26 weeks (6.6, 95% CI 1.4 to 11.8). Secondary outcomes and responder analyses also favoured physiotherapy functional restoration suggesting the differences were clinically important. Conclusions: In people with NRDP of ≥6 weeks and ≤6 months duration, individualised functional restoration was more effective than advice for all primary outcomes at 10 weeks and sustained at 26 weeks for activity limitation. Our results suggest that for people with NRDP not recovering after 6 weeks, an individualised physiotherapy functional restoration program should be considered. CONTRIBUTION OF PAPER: (1) A physiotherapist delivered functional restoration program individualised to pathoanatomical, psychosocial and neurophysiological barriers and incorporating guideline-based advice was more effective than advice alone in people with non-reducible discogenic low back pain of ≥6 weeks and ≤6 months duration. (2) This trial differs significantly from other studies on individualised physiotherapy, as it investigates a conservative management program that specifically targets the pathoanatomical subgroup non-reducible discogenic pain. ACTRN numbers: ACTRN12609000412235; ACTRN12609000834257.
... 64 Some authors have gone beyond attempts at a patho- anatomic diagnosis and suggested a mechanical classifi- cation where interventions can be properly tailored 11,[64][65][66][67] as already successfully demonstrated in other peripheral joints. 9,68,69 ...
Article
Background and purpose: Rotator cuff (RC) tendinopathy is a common disorder affecting many individuals, both in athletic and sedentary settings. Etiology of RC pathology or the most effective conservative treatment are not totally understood. The Mechanical Diagnosis and Treatment (MDT®) method is a widely known rehabilitative technique that allows therapists to diagnose and treat spinal, and peripheral mechanical disorders. Therefore, the purpose of this clinical commentary is to briefly describe RC tendinopathy, and its management using the MDT® method. Description of topic: RC tendinopathies are often named with several different terms, showing the difficulty related unambiguous terminology and the diagnostic process. Pathologies at the glenohumeral joint are mostly labeled according to anatomy or the impaired tissues rather than in a functional way. MDT® examination allows mechanical disorders of the shoulder to be classified into categories that show good outcomes when treated accordingly. Relation to clinical practice: The MDT® method may offer a practical, inexpensive, and effective solution to management of RC tendinopathies that present with a mechanical component. Level of evidence: 5.
... In this study, FP and AEP were studied because of their high prevalence (1,15). To classify the patients, the following diagnostic process was applied: 1) subjective examination of medical history, symptoms and activities aggravating or reducing the symptoms, 2) examination of physiological and accessory movements (with the thumb press directly on the spinous process of lumbar spine to determine the level of involvement) as well as 3) examination of functional movements including forward, backward, and side bending, and single-leg standing (16). ...
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Background: Balance disorder is one of the most-studied fields in low-back pain patients (LBP). However, there is insufficient information regarding the effect of LBP subgrouping on postural control. The purpose of the present study was to compare postural control between subgroups of chronic nonspecific LBP and healthy subjects during lifting. Methods: A total of 35 men with chronic LBP (19 active extension pattern [AEP] and 16 flexion pattern [FP]) and 15 healthy controls were enrolled in this cross-sectional study. Pooled LBP was subdivided based on the O'Sullivan's classification system (OCS). The participants were asked to lift a box from the ground to the waist level and hold it for 20 seconds. The load was 10% of the subject's weight. Force plate system was used to record balance parameters, including standard deviations (SDs) of center of pressure (COP) amplitude and COP velocity in anterior-posterior and medial-lateral directions and mean total velocity. The test was divided into two static and dynamic phases. Data were analyzed using one-way analysis of variance and independent t-test. Results: There were no significant differences between pooled LBP and control groups in any of the variables, except for the SD of the anterior-posterior direction velocity in the X-plane in the static phase (P=0.017). After classifying LBP, the results showed that the healthy and AEP groups were significantly different in SD of COP velocity in the frontal plane (P=0.021), mean total velocity (P=0.010), and SD of COP velocity in the sagittal plane (P=0.039). Conclusion: The present study showed that postural control was not different between the pooled LBP and normal groups. After classifying pooled LBP based on OCS, we found that the AEP showed different postural control as compared to healthy controls in the dynamic phase. The FP and AEP exhibited different postural control relative to the healthy controls in the static phase, and COP velocity was lower in those groups compared to the control group. The results of this study support the concept of LBP classification.
... The participants of this study not only described the challenges of "selling" the diagnosis of CNSLBP to their patient, but several also expressed their own skepticism about the diagnosis. While exploring the validity of the diagnosis is beyond the scope of this paper, its use remains contested in the literature and some authors have championed alternative classifications of CNSLBP presentations (Costa et al., 2013;McCarthy and Cairns, 2005;O'Sullivan, 2005O'Sullivan, , 2006Sheeran, Coales, and Sparkes, 2015;Turk, 2005). It has, for example, been proposed that the understanding of persistent pain may have become too polarized in the consideration of psychosocial factors, with a need to pay equal consideration to pathoanatomical causes of pain (Ford and Hahne, 2013). ...
Article
Introduction: Chronic nonspecific lower back pain (CNSLBP) is a common musculoskeletal condition which can be a source of significant distress and disability for patients. Approaches to managing CNSLBP have been explored in healthcare literature, as has the importance of communication in physiotherapy practice. However, no previous studies have explored clinicians’ experiences of communicating their understanding of this diagnosis to their patients. Methods: A qualitative research design, using hermeneutic phenomenological methodology, was employed. Five participants were purposively recruited for the research and data collected via semi-structured interviews. Interpretative phenomenological analysis (IPA) methods were used to analyze the data. Emergent, super-ordinate and master themes were developed to help convey the qualitative significant meanings of the lived-through experiences. Findings: Three master themes were identified, with each comprising two sub-themes. These were: 1) Patient-centeredness (1a. Understanding the patient; and 1b. emotional awareness and adaptability); 2) Getting patients “on board” (2a. the “selling” process; and 2b. paternalism and the clinician’s perspective); and 3) Dealing with conflict and uncertainty (3a. fear of interpersonal conflict; and 3b. personal doubts and uncertainty). Conclusions: Personal conflicts were identified between clinicians’ descriptions of their wishes to “sell” their own perspectives to patients while simultaneously wanting to demonstrate a patient-focused approach and avoid the interpersonal conflicts which arose from clashes with patients’ beliefs. Building a good initial rapport, showing empathy and adapting approaches in response to perceptions of patients’ reactions were perceived as strategies to help mitigate the risks of failed communication, but this was something for which participants felt unprepared by their prior training.
... 21 Identification of patient sub-groups based on posture, aberrant movement patterns and physical tests has been described. 22,23 Postural sub-groups have been based on the original posture types described by Kendall et al. 24 expanded to consider symptom provocation due to postural strain. For example, in the 'flexion pattern' symptoms are provoked by a slouched sitting posture (lumbar flexion) and with the 'extension pattern' symptoms are provoked with overhead activities and other motions held in lumbar segmental hyperextension. ...
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A controlled clinical trial. To assess the effects of an integrated back stability (IBS) programme on a chronic low back pain (CLBP) population in a time restricted private clinic environment. Studies assessing stability training CLBP have reported inconsistent results. Methods used within trials vary, with some authors focusing on muscle isolation and others using whole body movements. IBS uses an exercise progression beginning with posturally based exercise and progressing from muscle isolation through to complex movements. Fifty-nine chronic low back patients were divided into control (n=32) and intervention (n=27) groups. Participants in the intervention group were prescribed a 6 week individualized exercise programme in three stages. In stage 1, exercises addressed posture and movement dysfunction and activated the core stabilizing muscles. In stage 2, 'back fitness' was enhanced using progressive exercise principles. Stage 3 emphasized technique specific actions. Participants in the control group received a backcare advice leaflet only. Pre- and post-test scores were analysed for each of the outcome measures within the control group using a Wilcoxin signed ranks test. At an alpha level of p<or=0.0071, no differences were observed. For the intervention group, a Mann-Whitney U-test showed significant differences between groups in the Roland and Morris Disability Questionaire (RMDQ), short form McGill Pain Questionnaire (SF-MPQ), and the Tampa Scale of Kinesiophobia (TSK) (p<or=0.0071). Patient satisfaction was assessed by questionnaire, 89% of patients considering their level of pain and functional impairment acceptable following the programme. IBS significantly reduced pain and disability in the subject group studied. Patients reported a positive experience of the programme.
... 3,4 One subset of the classification system includes individuals who are thought to benefit from spine stabilization exercises. [5][6][7] The stabilization classification is a subgroup of patients who experience LBP as a result of faulty neuromuscular control, rather than from true ligamentous instability. 8,9 Muscular injury, fatigue, or facet or disc degeneration can compromise the stabilizing effects resulting in shearing forces that cause the pain. ...
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Postural re-education is an integral part of physiotherapy management in patients with back pain. Although the link between posture and back pain is largely unknown, postural re-education is performed on the premise of optimizing spinal alignment to minimize stresses on the passive structures of the spine, to facilitate optimal muscular support and thus to prevent possible damage and further pain. A reliable and clinically meaningful measurement of spinal postures to monitor such interventions remains challenging. This study evaluated within-day (intra-tester, inter-tester) and between-day (test-retest) reliability of a novel spinal wheel device measuring thoracic and lumbar postures during sitting and standing. 17 healthy volunteers (age 39.5 +/- 5.4, BMI 25 +/- 9.2; 9 males) were measured three times, by three testers, on two separate occasions (1 week apart). The angular change between C7 and T12 and between T12 and S1 provided thoracic and lumbar curvatures, respectively. Intra-class correlation coefficient (ICC) with 95% confidence intervals and typical error were calculated. Excellent reliability was demonstrated with intra-tester ICCs between 0.947 and 0.980 and typical error between 1.7 degrees and 3.7 degrees and inter-tester ICCs between 0.949 and 0.986 and typical error between 2.0 degrees and 4.7 degrees. Test-retest reliability was high with ICCs 0.719-0.908 and typical error between 4.0 degrees and 7.4 degrees. In conclusion, the spinal wheel demonstrated excellent within-day and high between-day reliability. The device may be used in conjunction with 2D camcorder to provide clinically useful visual evaluation of postures for assessment, intervention monitoring, and feedback during postural re-education.
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It has been proposed that patients with low back-related leg pain can be classified according to pain mechanisms into four distinct subgroups: Central Sensitization (CS), Denervation (D), Peripheral Nerve Sensitization (PNS), and Musculoskeletal (M). The purpose of this study was to determine whether there were any differences in terms of disability and psychosocial factors between these four subgroups. Forty-five subjects with low back-related leg pain completed the Oswestry Disability Index, the hospital Anxiety and Depression Scale, and the Fear Avoidance Beliefs Questionnaire. Subsequently, an examiner blinded to the questionnaire results classified the subjects into one of the four subgroups, according to the findings of the self-administered Leeds Assessment of Neuropathic Signs and Symptoms questionnaire and a physical examination. It was found that the PNS subgroup had significantly greater disability compared to all other subgroups and significantly greater fear avoidance beliefs about physical activity compared to the CS and D subgroups. This highlights the importance of sub-classification but also the need to take into account disability and psychosocial factors in the management of low back-related leg pain.
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A cross-sectional study between subgroups of nonspecific chronic low back pain (NSCLBP) and asymptomatic controls. To investigate NSCLBP subgroup differences in spinal position sense and trunk muscle activity when repositioning thoracic and lumbar spine into neutral (midrange) spinal position during sitting and standing. Patients with NSCLBP report aggravation of symptoms during sitting and standing. Impaired motor control in NSCLBP, associated with sitting and standing postures nearer the end range of spinal motion, may be a contributing factor. Rehabilitation improving neutral (midrange) spinal position control is advocated. Postural and motor control alterations vary in different NSCLBP subgroups, potentially requiring specific postural interventions. There is limited evidence on whether subgroup differences exist when performing neutral spine position tasks. Ninety patients with NSCLBP and 35 asymptomatic controls were recruited. Two blinded practitioners classified NSCLBP into subgroups of active extension pattern and flexion pattern. Participants were assisted into neutral spine position and asked to reproduce this position 4 times. Absolute, variable, and constant errors were calculated. Three-dimensional thoracic and lumbar kinematics quantified the repositioning accuracy and surface electromyography assessed back and abdominal muscles activity bilaterally. Irrespective of subclassification, patients with NSCLBP produced significantly greater error magnitude and variability than the asymptomatic controls, but subgroup differences were detected in the error direction. Subgroup differences in the trunk muscle activity were not consistently identified. Although both subgroups produced significantly higher abdominal activity, subclassification revealed difference in superficial multifidus activity during standing, with flexion pattern producing significantly greater activity than the asymptomatic controls. Subgroups of NSCLBP had similar neutral spinal position deficits regarding error magnitude and variability, but subclassification revealed clear subgroup differences in the direction of the deficit. The trunk muscle activation was shown to be largely nondiscriminatory between subgroups, with the exception of superficial lumbar multifidus.
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Statement: This is original work which has not been published (or submitted for publication) or presented at another national or international meeting at the present time. Title of Abstract: Differences in a neutral-spine-posture task during sitting and standing in nonspecific chronic low back pain disorders when patients are subclassified. Presenter: Liba Sheeran MSc, BSc (Hons) Contact Details: Liba Sheeran MSc, BSc (Hons), School of Healthcare Studies, Ty Dewi Sant, Heath Park, Cardiff University, Cardiff CF14 4XN, Wales, UK; Email: sheeranL@cardiff.ac.uk ; Tel: +447775668420 Authors: Liba Sheeran MSc Dr Valerie Sparkes PhD Professor Bruce Caterson PhD Dr Robert van Deursen PhD Dr Monica Busse-Morris PhD Purpose: To investigate motor control parameters during neutral spine posture task in sitting and standing in patients with non-specific chronic low back pain (NSCLBP)(combined and subclassified) compared to asymptomatic individuals (No-LBP). Relevance: Neutral spine posture awareness in important for spinal health and NSCLBP patients demonstrate deficits in repositioning neutral spine postures. Patients with different types of motor control impairments (MCI) appear to exhibit specific deficits, but little research exists to support this. Knowledge of neutral spine posture deficits in MCI subgroups could guide specific postural re-education interventions Methods A cross-sectional comparative study compared accuracy (absolute error), consistency (variable error) and direction (constant error) of repositioning error in thoracic, lumbar spine and pelvis during neutral-spine-posture task in sitting and standing in 90 NSCLBP patients with MCI and 35 asymptomatic individuals. Prior to testing, NSCLBP patients were subclassified by two blinded practitioners into 51 with flexion pattern (FP-MCI) and 39 with active extension pattern (AEP-MCI). Independent t-test compared differences between NSCLBP (combined) and No-LBP. One-way ANOVA with post-hoc compared differences between No-LBP, FP-MCI and AEP-MCI. Results Absolute error: NSCLBP (pooled) patients produced larger errors than No-LBP in sitting and standing, thoracic (p < 0.001; p < 0.001), lumbar spine (p < 0.001; p < 0.001) and pelvis (p < 0.001; p <0.001) respectively, with no difference between the MCI subgroups. Variable error: NSCLBP (combined) patients had higher variability compared to No-LBP in sitting and standing, thoracic (p < 0.05; p < 0.001), lumbar spine (p <0.001; p < 0.001) respectively. In the pelvic measures, while there was no difference between combined NSCLBP and No-LBP, subgroup analysis revealed that FP-MCI subgroup produced more variable errors in the pelvis (p < 0.05) in sitting than No-LBP. Constant error: Regardless of classification type, combined NSCLBP under-estimated the sitting and standing pelvic neutral target (p < 0.001; p <0.001 respectively) resulting in posterior pelvic tilt compared to No-LBP. In the spinal measures, while no difference was demonstrated in the direction of error in thoracic (sitting and standing) and lumbar spine (sitting and standing) measures between NSCLBP (combined) and No-LBP, clear opposing differences were identified between FP- and AEP-MCI subgroups compared to No-LBP in sitting and standing. In sitting, FP-MCI patients over-estimated the thoracic neutral target (p <0 .001) and under-estimated lumbar neutral target (p < 0.05) resulting in relatively flattened thoracic kyphosis and lumbar hypolordosis when compared to AEP-MCI and No LBP group. Conversely, AEP-MCI patients under-estimated the sitting thoracic neutral target (p < 0.05) and over-estimated sitting lumbar neutral target (p < 0.05) resulting in greater thoracic kyphosis and greater lumbar lordosis when compared to FP-MCI but not to No-LBP. In standing, while patients with FP-MCI demonstrated comparable spinal curvatures with asymptomatic controls patients , AEP-MCI significantly over-corrected the lumbar neutral target in standing resulting in increased lumbar lordosis when compared to asymptomatic subjects (p<0.05). Conclusion Differences in spinal and pelvic repositioning errors were found in NS-CLBP patients compared to healthy controls. Regardless of MCI type, NSCLBP patients demonstrated reduced accuracy (spine and pelvis) and consistency (spine) when performing neutral spine postures in sitting and standing. Significant subgroup differences were apparent however, in the direction of repositioning error in the spine and consistency of error in the pelvis when NSCLBP patients were subclassified into MCI subgroups. Implications Differences identified between two MCI subgroups, highlight the importance of subclassification and provide useful information guiding specific postural re-education interventions in these MCI subgroups.
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We would like to thank Hill et al (7) for taking the time to provide feedback on our recent publication in Pain (4). I would also like to thank the Editor for providing us the opportunity to respond to their comments. Our clinical trial investigated the addition of behavioral treatments (graded exercise and graded exposure) to physical therapy determined by clinical prediction rules. Results from the trial suggest no additional benefit from the behavioral treatments for patients with acute/sub-acute low back pain at 4-week and 6-month outcomes (4). Hill et al (7) suggest that one conclusion drawn from our data is that psychosocial interventions should be put “out to pasture – page XXX.” We would like to clarify that these are their words, not ours. Such a strong recommendation is unwarranted based on data from a single clinical trial. Our own interpretation of these data included several other equally feasible reasons for our null findings and our suggestions for future study included methodology that incorporates psychosocial interventions (4). Differences in interpretation aside, a primary issue that Hill et al (7) seem to have with our clinical trial is that the psychosocial sub-groups were determined in an “oversimplified” fashion. On this point we agree with the authors. In comparison to data available in 2008 for primary care (6) and physical therapy settings (3), the approach used to identify psychosocial sub-groups was simplified. In contrast, there were available data for physical therapy clinical prediction rules when this trial was being planned (1,5). We do, however, take umbrage with the description of this psychosocial sub-group identification as “arbitrary”. The same cut off score was used in a previous clinical trial reported by George et al (2). In this trial a differential treatment effect was observed such that those with elevated fear-avoidance beliefs had a greater benefit from graded exercise supplemented physical therapy. We believe the use of the same cut off score was an appropriate and necessary methodological choice for the follow up trial in which we attempted to replicate previously observed treatment effects. A secondary issue that Hill et al bring up is that our clinical trial was potentially underpowered, an important concern when null findings are reported. We disagree with the authors on this point. The prospective power analyses were based on effect sizes observed in our trial reported in 2003 (2). The observed effect sizes and power for the current trial were calculated, and were much smaller than in the previous trial. These data were reported to demonstrate how quite small these effects were, not to justify the need for larger studies in this area. The current trial was adequately powered to detect clinically meaningful effects, but not adequately powered to detect statistical significance of miniscule effects. Future study will determine if larger treatment effects are associated with more refined ways of determining psychosocial sub-groups, in comparison to readily available clinical prediction rules. This is a point we feel was made quite clearly in our manuscript; “Future study in patients with LBP should focus on improving the identification of patients at risk for developing chronic LBP and refining specific psychological targets that optimally reduce pain intensity in acute and sub-acute phase – page 157”(4). Sincerely,
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Category of presentation: Epidemiology: evidence based papers on effective diagnostic and therapy outcome DISCRIMINATING NON-SPECIFIC CHRONIC LOW BACK PAIN CLINICAL SUBGROUPS AND MONITORING RECOVERY USING AN OBJECTIVE CLASSIFICATION METHOD Sheeran L.1, Whatling G.2, Holt C.2, Beynon M. J.3, van Deursen R.1, Sparkes V.1 1Cardiff University, School of Healthcare Studies, Cardiff, UK; 2Cardiff University, School of Engineering, Cardiff, UK; 3Cardiff University, Cardiff Business School, Cardiff, UK. Introduction Heterogeneity of non-specific chronic low back pain (NSCLBP) can be deleterious to management success. Classification systems (CSs) that sub-classify NSCLBP to guide interventions often rely on clinical expertise and user familiarity. An objective classification method that alongside with clinical CSs aids classification and monitoring recovery with greater accuracy and less subjectivity is preferable. Aim To determine accuracy of an objective classification method based on Dempster-Shafer theory, the Cardiff Classifier (CC), discriminating healthy controls and clinical NSCLBP subgroups using sensory, spinal-pelvic repositioning error (RE) motor control (MC) parameters. To establish the most sensitive parameters discriminating NSCLBP subgroups from healthy and predicting recovery using CC. Materials and Methods Baseline and post-motor learning intervention (MLI) spinal-pelvic REs from 31 healthy (H) and 87 NSCLBP individuals with flexion (FP,n=50), passive extension (PEP,n=14) and active extension pattern (AEP,n=23) MC impairment subclassified by O’Sullivan’s CS were used. CC provided objective and visual indicators of NSCLBP subgroups, H and MLI effect. RE data were transformed into a set of three belief values: non-pathological function (NP), LBP characteristics and level of uncertainty. Each subject’s status was visually represented as a single point in a simplex plot (Figure 1). Subjects left of the central line have NP function; to the right have LBP characteristics. Results CC accuracy to discriminate FP and H was 85.2%(Figure1a), AEP and H 96.3%(Figure1b), PEP and H 100%(Figure1c). The most distinguishing parameter for FP was sitting lumbar RE, for AEP & PEP was standing lumbar RE. Combining all NSCLBP reduced CC accuracy to discriminate from H to 68.6% (Figure1d). CC distinguished pre/post-intervention REs with 85.7% accuracy for FP and 90% AEP, with sitting lumbar RE and standing pelvic RE as the most sensitive predictors of recovery, respectively. Figure 1. Simplex plots: a)FP+and H°, b)AEP+and H°, c)PEP+and H°, d)all NSCLBP+and H° Relevance Using CC in combination with clinical CS may enhance its accuracy by accounting for subjectivity related to varied clinical expertise levels and user familiarity. Using CC to identify key parameters characterizing each subgroup may focus recovery monitoring. Conclusions Using RE, CC accurately discerned three clinical NSCLBP subgroups, concurring with clinical CS. CC identified parameters most accurately characterizing each subgroup and predicting post-intervention recovery. Discussion This is the first CC application in NSCLBP. Importance of classification was illustrated with CC enhanced accuracy to discern between NSCLBP and H when patients were subclassified. CC should be further tested using clinical classification data. Implications NSCLBP classification is complex requiring synthesis of physical and clinical measures. CC can order complex data sets to aid clinicians’ interpretation and identify most sensitive parameters to efficiently monitor recovery, thereby enhancing classification robustness and usability. Keywords NSCLBP, objective classification, repositioning error, Dempster-Shafer
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The aim of this pilot study was to examine whether differences existed in spinal kinematics and trunk muscle activity in cyclists with and without non-specific chronic low back pain (NSCLBP). Cyclists are known to be vulnerable to low back pain (LBP) however, the aetiology of this problem has not been adequately researched. Causative factors are thought to be prolonged forward flexion, flexion-relaxation or overactivation of the erector spinae, mechanical creep and generation of high mechanical loads while being in a flexed and rotated position. Nine asymptomatic cyclists and nine cyclists with NSCLBP with a flexion pattern disorder primarily related to cycling were tested. Spinal kinematics were measured by an electromagnetic tracking system and EMG was recorded bilaterally from selected trunk muscles. Data were collected every five minutes until back pain occurred or general discomfort prevented further cycling. Cyclists in the pain group showed a trend towards increased lower lumbar flexion and rotation with an associated loss of co-contraction of the lower lumbar multifidus. This muscle is known to be a key stabiliser of the lumbar spine. The findings suggest altered motor control and kinematics of the lower lumbar spine are associated with the development of LBP in cyclists.
Article
The importance of classifying chronic low back pain (LBP) patients into homogeneous sub-groups has recently been emphasized. This paper reports on two studies examining clinicians ability to agree independently on patients' chronic LBP classification, using a novel classification system (CS) proposed by O'Sullivan. In the first study, a sub-group of 35 patients with non-specific chronic LBP were independently classified by two 'expert' clinicians. Almost perfect agreement (kappa-coefficient 0.96; %-of-agreement 97%) was demonstrated. In the second study, 13 clinicians from Australia and Norway were given 25 cases (patients' subjective information and videotaped functional tests) to classify. Kappa-coefficients (mean 0.61, range 0.47-0.80) and %-of-agreement (mean 70%, range 60-84%) indicated substantial reliability. Increased familiarity with the CS improved reliability. These studies demonstrate the reliability of this multi-dimensional mechanism-based CS and provide essential evidence in a multi-step validation process. A fully validated CS will have significant research and clinical application.
Article
This preliminary cross-sectional study was undertaken to determine if there were measurable relationships between posture, back muscle endurance and low back pain (LBP) in industrial workers with a reported history of flexion strain injury and flexion pain provocation. Clinical reports state that subjects with flexion pain disorders of the lumbar spine commonly adopt passive flexed postures such as slump sitting and present with associated dysfunction of the spinal postural stabilising musculature. However, to date there is little empirical evidence to support that patients with back pain, posture their spines differently than pain-free subjects. Subjects included 21 healthy industrial workers and 24 industrial workers with flexion-provoked LBP. Lifestyle information, lumbo-pelvic posture in sitting, standing and lifting, and back muscle endurance were measured. LBP subjects had significantly reduced back muscle endurance (P < 0.01). LBP subjects sat with less hip flexion, (P = 0.05), suggesting increased posterior pelvic tilt in sitting. LBP subjects postured their spines significantly closer to their end of range lumbar flexion in 'usual' sitting than the healthy controls (P < 0.05). Correlations between increased time spent sitting, physical inactivity and poorer back muscle endurance were also identified. There were no significant differences found between the groups for the standing and lifting posture measures. These preliminary results support that a relationship may exist between flexed spinal postures, reduced back muscle endurance, physical inactivity and LBP in subjects with a history of flexion injury and pain.
Article
Low back pain (LBP) is a very common but largely self-limiting condition. The problem arises however, when LBP disorders do not resolve beyond normal expected tissue healing time and become chronic. Eighty five percent of chronic low back pain (CLBP) disorders have no known diagnosis leading to a classification of 'non-specific CLBP' that leaves a diagnostic and management vacuum. Even when a specific radiological diagnosis is reached the underlying pain mechanism cannot always be assumed. It is now widely accepted that CLBP disorders are multi-factorial in nature. However the presence and dominance of the patho-anatomical, physical, neuro-physiological, psychological and social factors that can influence the disorder is different for each individual. Classification of CLBP pain disorders into sub-groups, based on the mechanism underlying the disorder, is considered critical to ensure appropriate management. It is proposed that three broad sub-groups of CLBP disorders exist. The first group of disorders present where underlying pathological processes drive the pain, and the patients' motor responses in the disorder are adaptive. A second group of disorders present where psychological and/or social factors represent the primary mechanism underlying the disorder that centrally drives pain, and where the patient's coping and motor control strategies are mal-adaptive in nature. Finally it is proposed that there is a large group of CLBP disorders where patients present with either movement impairments (characterized by pain avoidance behaviour) or control impairments (characterized by pain provocation behaviour). These pain disorders are predominantly mechanically induced and patients typically present with mal-adaptive primary physical and secondary cognitive compensations for their disorders that become a mechanism for ongoing pain. These subjects present either with an excess or deficit in spinal stability, which underlies their pain disorder. For this group, physiotherapy interventions that are specifically directed and classification based, have the potential to impact on both the physical and cognitive drivers of pain leading to resolution of the disorder. Two case studies highlight the different mechanisms involved in patients with movement and control impairment disorder outlining distinct treatment approaches involved for management. Although growing evidence exists to support this approach, further research is required to fully validate it.
Article
A comparative study. To investigate sitting postures of asymptomatic individuals and nonspecific chronic low back pain (NS-CLBP) patients (pooled and subclassified) and evaluate the importance of subclassification. Currently, little evidence exists to support the hypothesis that CLBP patients sit differently from pain-free controls. Although classifying NS-CLBP patients into homogeneous subgroups has been previously emphasized, no attempts have been made to consider such groupings when examining seated posture. Three angles (sacral tilt, lower lumbar, and upper lumbar) were measured during "usual" and "slumped" sitting in 33 NS-CLBP patients and 34 asymptomatic subjects using an electromagnetic measurement device. Before testing, NS-CLBP patients were subclassified by two blinded clinicians. Twenty patients were classified with a flexion motor control impairment and 13 with an active extension motor control impairment. No differences were found between control and NS-CLBP (pooled) patients during usual sitting. In contrast, analyses based on subclassification revealed that patients classified with an active extension pattern sat more lordotic at the symptomatic lower lumbar spine, whereas patients with a flexion pattern sat more kyphotic, when compared with healthy controls (F = 19.7; df1 = 2, df2 = 63, P < 0.001). Further, NS-CLBP patients had less ability to change their posture when asked to slump from usual sitting (t = 4.2, df = 65; P < 0.001). Differences in usual sitting posture were only revealed when NS-CLBP patients were subclassified. This highlights the importance of subclassifying NS-CLBP patients.
A contemporary approach to manual therapy
  • R Elvey
  • O Sullivan
Elvey R, O'Sullivan P. A contemporary approach to manual therapy. Amssterdam: Elsevier; 2004.
The back pain revolution
  • G Waddell
Waddell G. The back pain revolution. Edinburgh: Churchill Livingstone ; 2004.