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The use of a mechanism-based classification system to evaluate and direct management of a patient with non-specific chronic low back pain and motor control impairment- A case report

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... Over 80% percent of people experience low back pain (LBP), and despite the growing research on assessment and treatment of LBP, 85% of the cases go undiagnosed and remain characterized as non-specific LBP (O' Sullivan, 2005;Dankaerts et al., 2007;O'Sullivan and Beales, 2007;Monie, Fazey and Singer, 2016). Up to 40% percent of those cases will become chronic (O' Sullivan, 2005). ...
... Up to 40% percent of those cases will become chronic (O' Sullivan, 2005). To identify primary cause(s) and better predictability of the non-specific LBP, researchers are proposing a multimodal approach to the assessment and management of the LBP, and classification of patients based on the functional movement impairment (O'Sullivan, 2005;Dankaerts et al., 2007;Jull and Moore, 2012). Active straight leg raise (ASLR) is the most widely used diagnostic tests for LBP (Hu et al., 2012), but there is a lack of evidence of association with other clinical parameters, and functional analyses used in evaluation of LBP. ...
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With high rates of active population experiencing undiagnosed, nonspecific low back pain, a new approach is needed with consideration of dysfunctional movement patters that may lead to chronic back pain. Active straight leg raise (ASLR) is widely used diagnostic tests for LBP, but there is a lack of evidence of association with other clinical parameters and functional analyses used in evaluation of LBP. Hence, the primary aim of this study is to investigate association of ASLR test with the movement deficiencies in muscles and joints responsible for lumbo-pelvic stability in populations with and without low back pain. 100 physically active participants with (n=50) and without LBP (n=50) volunteered for the study. One-way ANOVA was used to examine for potential differences between two groups, and multiple correspondence analysis (MCA) to examine the pattern of relationships between the measured variables. Participants without pain had significantly higher ASLR score (p < 0.001), demonstrated better hamstring flexibility (p < 0.001) and better gluteal activation pattern (p < 0.01). On the other hand, participants with LBP had greater incidence of pelvic rotation during knee flexion, and hip internal rotation, relative to participants without LBP (p < 0.001). Results also demonstrate that participants with pain scored largely 1 on the ASLR which was also associated with hamstring tightness, calf tightness, limited trunk flexion, hypo-mobility of the trunk, and posterior pelvic tilt. These findings indicate a strong association of low back pain with functional movement impairment and weakness in movement motor control. ASLR test should be used conjunction with other functional evolution tests to isolate the cause of LBP in physically active individuals.
... One suggested subgroup within the NSLBP population are patients with a movement control impairment (MCI) (O'Sullivan, 2005) (e.g. Fig. 1) who are proposed to suffer from a lack of active control of their lumbar spine movements (O'Sullivan, 2005;Dankaerts et al., 2007). Efficient and adaptive motor function requires accurate and precise sensory information (Moseley, 2007) and there is now growing evidence supporting the idea of altered sensory function in people with low back pain, particularly a loss of sensory acuity (Wand et al., 2011a,b Q2 ). ...
... To determine if the combination of motor control and sensory acuity training improved outcome paired t-tests, for parametric data, and Wilcoxon rank tests (Wilcoxon et al., 1961), for non-parametric data, were performed to compare baseline scores with scores at the end of treatment. The effect size for within group change was calculated for the RMQ, the PSFS, MCTB and TPD using Cohen's d (Cohen, 1992). A large effect was defined as >0.8, a moderate effect between 0.2 and 0.8 and a small effect <0.2. ...
... This is attributed to failure to recognise heterogeneity within non-specific LBP and failure to individualise treatments. Promising results are emerging when patients and treatments are matched using subgrouping [2][3][4][5][6][7][8], but this is not universal [9] and results are mixed [10]. Subgrouping approaches for non-specific LBP share a common premise; more predictable and favourable outcomes will be achieved if similar presentations among individuals are recognised (a subgroup), and an intervention specific to http://dx.Please cite this article in press as: Karayannis NV, et al. ...
... On the basis of similarities in the criteria used to classify patients into the OSC control multidirectional and TBC stabilisation categories, it was hypothesised that these subgroups would be closely aligned. Criteria for the OSC control multidirectional subgroup include: (1) exhibit combinations of other OSC control impairment subgroups; (2) show multidirectional impairments of lumbo-pelvic control; (3) have an increase in symptoms with multiple directions; (4) demonstrate a decrease in symptoms in neutral spine postures; (5) have positive movement test findings in both flexion and extension directions; and (6) are typified by chronic disabling pain disorders. Criteria for the TBC stabilisation subgroup include: (1) a history of three or more episodes of LBP; (2) presence of standing flexion aberrant motion; (3) a failure to centralise; and (4) a hypermobile lumbar spring test. ...
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Classification systems for low back pain (LBP) aim to guide treatment decisions. In physiotherapy, there are five classification schemes for LBP which consider responses to clinical movement examination. Little is known of the relationship between the schemes. To investigate overlap between subgroups of patients with LBP when classified using different movement-based classification schemes, and to consider how participants classified according to one scheme would be classified by another. Cross-sectional cohort study. University clinical laboratory. One hundred and two participants with LBP were recruited from university, hospital outpatient and private physiotherapy clinics, and community advertisements. Participants underwent a standardised examination including questions and movement tests to guide subgrouping. Participants were allocated to a LBP subgroup using each of the five classification schemes: Mechanical Diagnosis and Treatment (MDT), Movement System Impairment (MSI), O'Sullivan Classification (OSC), Pathoanatomic Based Classification (PBC) and Treatment Based Classification (TBC). There was concordance in allocation to subgroups that consider pain relief from direction-specific repeated spinal loading in the MDT, PBC and TBC schemes. There was consistency of subgrouping between the MSI and OSC schemes, which consider pain provocation to specific movement directions. Synergies between other subgroups were more variable. Participants from one subgroup could be subdivided using another scheme. There is overlap and discordance between LBP subgrouping schemes that consider movement. Where overlap is present, schemes recommend different treatment options. Where subgroups from one scheme can be subdivided using another scheme, there is potential to further guide treatment. An integrated assessment model may refine treatment targeting. Copyright © 2015 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
... They suggested that the absence of the FR phenomenon may initially be a response to pain, but a persistent abnormal pattern may be related to psychophysiological rather than physical factors in chronic conditions. Dankaerts et al. proposed that among several hypotheses regarding mechanisms affecting trunk muscle recruitment patterns in chronic low back pain, the deficit in motor control will lead to poor control of joint movement and pain in some people with back pain (Dankaerts et al., 2007). Although it is not clear that altered trunk activation pattern is the result of pain or not (Williams et al., 2010), Hodges et al. suggested that the most likely reasons are due to the influence of pain on sensory and motor centers and also cognitive factors (Hodges and Moseley, 2003). ...
... In the present study, we saw different responses of LM and ICLT activity during forward flexion in the two groups. This finding may be due to their different roles during lumbar functional tasks (Danneels et al., 2001) or different motor responses of the back muscles during static positions (sitting) and movements (Dankaerts et al., 2007(Dankaerts et al., , 2009b. We did not see significant improvement in the FRR of LM post-intervention for either treatment group, although the movement control group showed higher FRR for LM. ...
Article
Background: Exercise is considered an effective treatment strategy for non-specific chronic low back pain (NSCLBP).background In spite of the wide use of exercise protocols, it is not clear what type of exercise is more effective in decreasing pain, disability and normalizing muscle activation patterns in people with chronic low back pain. Objectives: To assess the effects of two exercise protocols (stabilization vs movement control) on pain and disability scores and the flexion relaxation ratio (FRR) of lumbar multifidus (LM) and iliocostalis lumbarum pars thoracic (ICLT) in people with extension related non-specific chronic low back pain. Study design: Pilot randomized control trial. Methods: 32 subjects with active extension pattern chronic low back pain (stabilization group = 16, movement control group = 16) participated in this study. Treatment groups received 4 weeks of exercise therapy. Outcomes were based on pain score (Numeric rating Scale-NRS), disability (Oswestry Disability Index- ODI) and FRR of the LM and ICLT. Results: Four people dropped out of the study in each group for reasons unrelated to the protocols of the study. Pain and disability reduced in both groups, with no significant difference between the groups. The FRR of LM did not change in either treatment group after treatment. However, the FRR of ICLT was significantly increased after treatment in the movement control group. Conclusion: Both movement control and stabilization exercises reduced pain and disability in the short-term among people with extension pattern NSCLBP, with no difference in effectiveness between the groups. However, movement control exercises were more effective in normalizing back muscle activation patterns than stabilization exercises.
... It has been demonstrated that differences in posture among people with NSCLBP may only be evident when subgrouping is performed based on the direction of pain provocation in patients with mechanically provoked NSCLBP (Dankaerts et al. 2006b). For example, there is evidence that subjects with mechanically provoked NSCLBP may present with increased lumbar flexion or extension, and that modification of sitting posture may be more effective when matched to their individual presentation (Dankaerts et al. 2006a(Dankaerts et al. , 2006b(Dankaerts et al. , 2007. Therefore, among subjects with mechanically provoked NSCLBP, assuming 'neutral' sitting postures which avoid end-range flexion or extension may be of benefit as one component of NSCLBP rehabilitation . ...
... Participants were further classified into two NSCLBP subgroups (O'Sullivan 2005); (i) active extension pattern (AEP) (n ¼ 14) and (ii) flexion pattern (FP) (n ¼ 10). These two NSCLBP subgroups are detailed in Table 1, but in brief they have been shown to present with distinctive patterns of increased lumbo-pelvic extension (AEP) and increased lumbo-pelvic flexion (FP) (Dankaerts et al. 2006a(Dankaerts et al. , 2006b(Dankaerts et al. , 2007. It has been proposed that postural modification for these two NSCLBP subgroups should be very different, with the AEP subgroup benefitting from increased lumbo-pelvic flexion and the FP subgroup benefitting from increased lumbo-pelvic extension (O'Sullivan 2005). ...
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Unlabelled: A total of 24 participants with non-specific chronic low back pain (NSCLBP) sat for 2 h while their seated posture and low back discomfort (LBD) were analysed. A total of 16 pain developers (PDs), whose LBD increased by at least two points on the numeric rating scale, repeated the procedure 1 week later, while receiving postural biofeedback. PDs were older (p = 0.018), more disabled (p = 0.021) and demonstrated greater postural variability (p < 0.001). The ramping up of LBD was reduced (p = 0.002) on retesting, when sitting posture was less end-range (p < 0.001), and less variable (p = 0.032). Seated LBD appears to be related with modifiable characteristics such as sitting behaviour. Among people with sitting-related NSCLBP, the ramping up of LBD was reduced by modifying their sitting behaviour according to their individual clinical presentation. The magnitude of change, while statistically significant, was small and no follow-up of participants was completed. Further research should examine integrating biofeedback into comprehensive biopsychosocial management strategies for NSCLBP. Practitioner summary: The effect of real-time postural biofeedback on LBD was examined among people with LBP. Postural biofeedback matched to the individual clinical presentation significantly reduced LBD within a single session. Further research should examine the long-term effectiveness of postural biofeedback as an intervention for LBP.
... Optimal treatment remains a great mystery, but there are some randomized trials suggest some improvement of which is scientifically proven. Nevertheless, it was found that people with LBP, have impaired motor control, which varies greatly depending on each person 30 . ...
... These include changes in posture (Roussouly et al., 2005;Dankaerts et al., 2006b;Claus et al., 2009;Consmuller et al., 2012), muscle activation (van Dieën et al., 2003;Dankaerts et al., 2006a), and movement (Wong and Lee, 2004;MacDonald et al., 2009;Scholtes et al., 2009;Mok et al., 2011). Such changes have been used as a basis to identify homogeneous subgroups within the heterogeneous LBP population (Dankaerts et al., 2007(Dankaerts et al., , 2009; Dankaerts and O'Sullivan, 2011;Fersum et al., 2009;Harris-Hayes and Van Dillen, 2009). However, examination of motor behaviour often requires sophisticated laboratory tests that have limited utility in clinical practice. ...
Article
LBP is often associated with changes in motor control. Some subgroups of LBP have been argued to have a compromised ability to dissociate lumbopelvic movement from that of the thoracolumbar junction. Clinical methods to evaluate this task may aid identification of this LBP subgroup and determine the utility of this information to guide clinical interventions. The study aimed to develop a clinical test to assess the ability to dissociate lumbopelvic movement from that of the thoracolumbar junction, and to evaluate the inter-rater reliability of the test in individuals with and without low back pain (LBP) when performed by experienced and novice therapists. A clinical scale was developed to characterise quality of performance of lumbopelvic motion with limited motion at the thoracolumbar junction. Inter-tester repeatability was measured in three experiments. Test outcomes for pain-free controls were compared between three assessors with different amounts of clinical experience. Test scores for LBP participants were compared between two assessors, and between assessments undertaken from video recordings. Agreement between assessors was tested with weighted Kappa Coefficient. The test had acceptable reliability in pain-free and LBP participants, but was better when undertaken by experienced therapists. Kappa index ranged from 0.81-0.66 for live assessments, and 0.62 for video assessments. The results showed that the test is reliable when performed by experienced assessors. The test can assess thoracolumbar movements in different groups of individuals.
... die Flexionsbewegung sehr viel wahrscheinlicher in der LWS sattfinden, was zu einem Schmerzproblem des Rückens führen kann. Zwar wurden schon Befunde und Behandlungsmaßnahmen für die Dysfunktionen der Bewegungseinschränkungen aufgestellt [3,4,8,25,26,28,31,34], allerdings gibt es nur sehr wenige Studien zur Feststellung der Test-Reliabilität. Auch Studien, die den Erfolg solcher Behandlungen bei der Untergruppe untersuchen, fehlen noch. ...
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Patienten mit Dysfunktionen der aktiven Bewegungskontrolle bilden moglicherweise eine wichtige Untergruppe mit Schmerzen in der LWS. Die Diagnosestellung basiert auf der Beobachtung der aktiven Bewegungen. Obwohl die Tests im klinischen Alltag weit verbreitet sind, finden sich nur wenige Untersuchungen zu ihrer Reliabilitat. Das Ziel dieser Studie bestand darin, die Inter- und Intrabeobachter-Reliabilitat der Bewegungskontrolldysfunktionstests der LWS zu untersuchen. Patients with movement control dysfunction may be an important subgroup within lumbar spinal pain. The diagnosis is based on monitoring active movements. Although widely used in clinical practice only few investigations concerning their reliability have been carried out. This study aimed at determining the interrater and intrarater reliability of movement control dysfunction tests for the lumbar spine.
... The lack of movement awareness and control of the lumbopelvic region leads to an inappropriate movement behaviour with provocative movement and posture patterns. According to previous authors, this mechanism leads to a tissue overload and mechanically provoked pain (Dankaerts et al., 2007;O'sullivan, 2005). Impairment-specific exercises for movement awareness and control of the lumbopelvic region are effective for patients with NSLBP and movement control impairment (Costa et al., 2009;Macedo et al., 2012). ...
Article
Specific exercises for the improvement of movement control of the lumbopelvic region are well-established for patients with non-specific low back pain (NSLBP) and movement control impairment (MCI). However, a lack of adherence to home exercise regimens is often observed. The aim of the study was to explore the differences in home exercise (HE) adherence between patients who perform conventional exercises and those who exercise with Augmented Feedback (AF). Twenty patients with NSLBP and MCI were randomly allocated into two groups. The physiotherapy group (PT group) completed conventional exercises, and the AF group exercised with an AF system that was designed for use in therapy settings. The main outcome measure was self-reported adherence to the home exercise regimen. There was no significant difference in HE duration between the groups (W= 64, p= 0.315). The AF group exercised for a median of 9 min and 4 s (IQR= 3’59’’), and the PT group exercised for 4 min and 19 s (IQR= 8’30’’). Exercising with AF led to HE times that were similar to those of conventional exercise, and AF might be used as an alternative therapy method for home exercise.
... It has been documented that in spite of the large number of pathological conditions that can result in LBP, 85% of these are without pathoanatomical / radiological abnormalities (1). It is the Nonspecific Chronic Low Back Pain (NCLBP) population which frequently develops into a chronic fluctuating problem with irregular flares (2). ...
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Objectives: In a single blinded randomized controlled study, we investigated the effect of stabilization exercise on lumbar multifidus muscle thickness in patients with non-specific chronic low back pain. Low Back Pain is highly prevalent and results in considerable level of disability. Many causes have been associated with weakness or injury of the soft tissues in the lumbar area. Methods: A total of 122 individuals (44 males, 78 females) with non-specific chronic low back pain participated in this study. They were assigned to four different groups. Group 1 received stabilization exercise only. In addition to stabilization exercise, groups 2 and 3 received Transcutaneous Electrical Nerve Stimulation and massage therapy respectively and group 4 was the control group who received drug therapy only. Participants went through this protocol twice weekly for 8 consecutive weeks. Measurement of muscle thickness using Ultrasound scanning machine was done at baseline and end of 8th week. Analysis of variance was used to determine significant difference at P
... Examination and treatment options for movement impairment dysfunctions have been proposed. [4,5,7,[9][10][11]13,14]. However, only a few studies have been performed to determine test reliability. ...
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Background: Movement control dysfunction [MCD] reduces active control of movements. Patients with MCD might form an important subgroup among patients with non specific low back pain. The diagnosis is based on the observation of active movements. Although widely used clinically, only a few studies have been performed to determine the test reliability. The aim of this study was to determine the inter-and intra-observer reliability of movement control dysfunction tests of the lumbar spine.
... Several classification systems have been proposed [30] and O'Sullivan's classification systems seems thus far to show the most promise [26, 27, 30, 33, 34]. O'Sullivan differentiates patients with CLBP into three main subgroups [ 3. Patients whose motor control alterations are contributing to their CLBP either through movement limitations or motor control limitations In O'Sullivan's model the first group are likely to benefit from manual therapy interventions with the possible addition of motor control retraining to restore normal movement patterns. ...
Article
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Current clinical practice amongst many physiotherapy and clinical exercise professionals includes application of the research showing altered timing of transversus abdominis and multifidus in patients with chronic lower back pain, but does current research support this position? This article examines the current research to determine best practice for low back rehabilitation.
... 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). ...
Article
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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.
... Diagnostic, observational and interpretive skills are required to triage patients and analyse functional and pain behaviours in order to determine adaptive from maladaptive behaviours. Targeted management requires clinicians to communicate effectively, 66 teach body relaxation strategies, 67 normalize functional movement patterns and discourage pain behaviours, 68 utilizing mindfulness 69 and motivational 70 principles for behavioural change. Feedback (visual, sensory and verbal) 71,72 and activity pacing 73 are components of this process. ...
... The MCI is a clear sub-group of non-specific low back pain. Pathokinesiological movement patterns in the lumbar spine have been investigated and described [36][37][38][39][40]. A significant difference between subjects with and without LBP in the ability to actively control the movements of the low back has been demonstrated by Luomajoki et al. (2008) [28]. ...
... The MCI is a clear sub-group of non-specific low back pain. Pathokinesiological movement patterns in the lumbar spine have been investigated and described [36][37][38][39][40]. A significant difference between subjects with and without LBP in the ability to actively control the movements of the low back has been demonstrated by Luomajoki et al. (2008) [28]. ...
Article
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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.
... While it is possible that the changes help alter spinal loading patterns in a helpful manner, there is increasing evidence that many of the changes observed in people with persistent pain are not necessarily adaptive. In fact, there is preliminary evidence that normalizing these movement patterns to more closely resemble those of people without pain is associated with reduced pain and disability (Dankaerts et al., 2007). In this scenario, actively holding the lumbar spine at more extension may increase loading of posterior spinal structures. ...
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.
... The physical examination process involved a systematic process of assessment of pain provocative postures (such as sleeping, sitting, standing and bending) and functional movement tasks (such as sit to stand, single-leg stand, spinal movements and lifting) and any other specific tasks nominated by the patient as pain provocative or that they avoided. The validity of this clinical examination approach has been demonstrated in a number of studies (O'Sullivan et al., 2006a,b;Dankaerts et al., 2007;O'Sullivan and Beales, 2007a,b;Beales et al., 2009;Dankaerts et al., 2009;Sheeran et al., 2012). The reliability has pre-viously been reported for both physical and cognitive aspects based on the health-care practitioners' ability to synthesize the patient story and clinical examination to broadly classify the patient, based on identification of the primary drivers of the disorder within the different levels of the MDCS (Dankaerts et al., 2006;Fersum et al., 2009). ...
Article
Objective: Little is known about how static standing balance changes post total knee arthroplasty (TKA). The primary aim of this study was to examine the sensitivity to change and redundancy of center of pressure (COP) variables post-TKA. The secondary aim was to compare the sensitivity of these measures to standard clinical assessments of one repetition maximum knee extension strength and fast pace gait speed. Design: 466 participants performed instrumented double-limb standing balance tests with eyes open at four and 12 weeks post-TKA. Measures of COP standard deviation, amplitude, root mean square, path length, detrended fluctuation analysis (DFA) and signal frequency content for the medial-lateral (ML) and anterior-posterior (AP) axes were examined. Results: Significant decreases in total path length, ML variables related to sway velocity and AP signal complexity and frequency were observed. Inter-session Cohen's d effect size (ES) revealed the strongest effect was for high velocity ML path length, with a 12% decrease in this rapid sway. This variable, along with AP mean instantaneous frequency and AP DFA, were the only ones significantly different with effect sizes >0.20 and non-redundant (Spearman's rho <0.75). The ES of COP-derived variables (maximum = 0.45) were lower than gait speed (1.40) and knee extensor strength (1.54). Conclusion: Increased high velocity ML sway is present at four compared to 12 weeks post-TKA. This augmented rapid sway may provide increased challenges to the postural control system at a time coinciding with reduced strength levels, which could have implications for physical function during activities of daily living.
... 4 One possible factor in the development of non-specific chronic LBP (NSCLBP) is poor lumbar movement control (LMC). [5][6][7][8][9] However, there are still controversies regarding the contribution of movement control (MC) to LBP, such as whether pain is the cause or the consequence of maladaptive movement control strategies. 10 Previous theories regarding MC have been dominated by biomechanical assumptions. ...
Article
Question What tests are most useful to identify poor lumbar movement control (LMC) and what are the dimensional and psychometric properties of these tests? Design Multicenter, cross-sectional cohort study. Participants Adults with non-specific chronic low back pain (NSCLBP). Methods A literature review was conducted to identify LMC tests with good reliability (κ≥0.61) and their diensionality examined. Based on item response theory, psychometric properties of individual items and the entire battery of LMC tests were determined. Results 277 participants with NSCLBP were included and tested by 21 physiotherapists in 19 clinics in Germany and Austria. 15 tests for LMC were assessed. The battery of LMC tests showed a direction-specific structure representing extension, flexion and rotation/lateral flexion control, for which unidimensionality and local independence were confirmed (eigenvalue >1; factor loading >0.4, Yen´s Q3 <0.2). 4 items for flexion control, 4 items for extension control and 5 items for rotation/lateral flexion control were extracted. The flexion control items were the easiest items (item difficulty: -1.98 to -1.31). The rotation/lateral flexion control items were the most difficult (-1.3 to -0.08). More than 80% of all participants showed at least one incorrect direction of LMC. Conclusions A battery of LMC tests is proposed as the most appropriate to examine individuals with precise to poor LMC. Each direction of LMC should be examined separately. Tests can be ordered according to test difficulty, so that only three tests are initially required to screen for poor LMC.
... The physical examination process involved a systematic process of assessment of pain provocative postures (such as sleeping, sitting, standing and bending) and functional movement tasks (such as sit to stand, single-leg stand, spinal movements and lifting) and any other specific tasks nominated by the patient as pain provocative or that they avoided. The validity of this clinical examination approach has been demonstrated in a number of studies (O'Sullivan et al., 2006a,b;Dankaerts et al., 2007;O'Sullivan and Beales, 2007a,b;Beales et al., 2009;Dankaerts et al., 2009;Sheeran et al., 2012). The reliability has pre-viously been reported for both physical and cognitive aspects based on the health-care practitioners' ability to synthesize the patient story and clinical examination to broadly classify the patient, based on identification of the primary drivers of the disorder within the different levels of the MDCS (Dankaerts et al., 2006;Fersum et al., 2009). ...
... These data were collected as part of a larger study (Dankaerts, 2006) therefore PASS power analysis (Hintze, 2008) calculations were performed retrospectively to determine the power to detect a one standard deviation ( ...
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Sit-to-stand (STS) is a functional dynamic task, requiring movement of the lumbar spine, however, little is known about whether regional differences or between-gender differences exist during this task. The aim of this study was to confirm whether kinematic differences existed within regions of the lumbar spine during STS and also to determine whether between-gender differences were evident. An electromagnetic measurement device, recording at 25 Hz, determined how different lumbar spine regions (combined, lower and upper) moved during STS in 29 healthy participants (16 males, 13 females). Discrete outputs including mean range of motion (ROM), maximum and minimum were calculated for each lumbar spine region. Analyses of covariance (ANCOVA) with repeated measures were used to determine whether regional differences and between-gender differences were evident in the lumbar spine during STS. With the lumbar spine modelled as two segments, the lower lumbar (LLx) and upper lumbar (ULx) regions made different contributions to STS: F1, 27 = 21.8; p < 0.001. No between-gender differences were found with the lumbar spine modelled as a single region (combined lumbar: CLx), however, modelled as two regions there was a significant gender difference between the LLx and ULx regions: F1, 27 = 7.3 (p = 0.012). The results indicate that modelling the lumbar spine as a single segment during STS does not adequately represent lumbar spine kinematics and there are important gender differences. These findings also need to be considered when investigating STS in clinical populations.
... [1][2][3][4] Alterations have been described in relation to the timing of muscle onset 5 and peak amplitude of muscle activity 6,7 as well as changes in the overall profile of the electromyography (EMG) signal. [7][8][9] Despite these observations, the underlying mechanism behind such alterations is not well understood. ...
Article
The aim of this study was to use an experimental pain relief model to determine the effect of pain relief on lumbar muscle function in people with low back pain. A test-retest design was used with all data collection being completed within a therapy setting. Twenty people with acute and 20 with chronic low back pain were recruited from general practitioner and therapist referrals. Participants completed spinal movements and lifting. Electromyography (EMG) was used to measure the pattern of muscle activity, onset of muscle activation, and peak activation of bilateral lumbar multifidus and iliocostalis. Movements were investigated before and after pain relief, through the self-administration of oral analgesia. Electromyography profiles and peak values were reliable across 3 trials, and EMG profiles correlated well with kinematic profiles. Specific EMG profiles were commonly associated with specific kinematic values, and on the whole, the EMG profiles were unaffected by pain relief. Muscle onset times and peak muscle amplitudes were not affected by pain relief in either acute or chronic low back pain. This study showed that the EMG activities from the lumbar region, including lumbar multifidus and iliocostalis, are reliable, and specific EMG profiles are identifiable. Pain relief as achieved in this study did not affect the pattern of EMG activity, onset of muscle activation, or peak activation values.
... Sorri-Bauru Estesiometro filaments (Sorri-Bauru Institute, Bauru, Sao Paulo, Brazil, www.sorribauru.com.br) are colourcoded nylon monofilaments with nominal bending forces of 0.05, 0.2, 2, 4, 10, and 300 g (equalling ;0.5, 2.0, 19.6, 39.2, 98.0, and 2940 mN, respectively). 5 In contrast to the DFNS glass monofilaments, the tips are not rounded and hence have potentially sharp edges, and their diameters vary between 0.12 mm and 1.14 mm (Fig. 1C). For this reason and the broad range of force they cover, this set of filaments was used to test both MDT and MPT. ...
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Introduction:. Quantitative sensory testing is used to assess somatosensory function in humans. The protocol of the German Research Network on Neuropathic Pain (DFNS) provides comprehensive normative values using defined tools; however, some of these may not be feasible in low-resource settings. Objectives:. To compare the standard DFNS devices for assessment of mechanosensory function to a low resource tool, the Sorri-Bauru-monofilaments. Methods:. Mechanical detection thresholds (MDT), pain thresholds (MPT), and suprathreshold pinprick ratings (pain sensitivity: MPS) were measured over cheek, hand dorsum, and fingertip in 13 healthy subjects (7 female, aged 21–44 years). Mechanical detection threshold was assessed with DFNS standard glass monofilaments (0.25–512 mN, 0.5 mm tip) and nylon monofilaments (Sorri-Bauru; 0.5–3000 mN). MPT was assessed with DFNS standard cylindrical probes (8–512 mN, 0.25 mm tip), Sorri-Bauru monofilaments, and with ramped stimuli using an electronic von Frey aesthesiometer (10 mN/s or 100 mN/s, 0.20 mm tip). MPS was measured in response to stepped and ramped pinpricks (128 and 256 mN). Results:. Mechanical detection thresholds were the same for DFNS and Sorri-Bauru monofilaments. For MPT, Sorri-Bauru filaments yielded lower values than PinPricks over face but not hand. Pain thresholds were higher at all test sites for ramped than stepped pinpricks (P < 0.01). Suprathreshold ratings were lower for ramped than stepped pinpricks (P < 0.05). Conclusion:. Sorri-Bauru filaments are acceptable substitutes for DFNS standards in estimating tactile sensitivity, but are not consistent with standard probes for pinprick sensitivity because of their nonstandardized tips. Ramped stimuli overestimated MPT and underestimated MPS due to reaction time artefacts and therefore need their own normative values.
... 21,62,63 Promising results related to this approach were previously described. 28,51,53,[64][65][66][67][68][69] However, most of the classification systems failed to show clinically significant differences in outcomes when compared to other therapies not based on subgrouping in randomized controlled trials involving people with chronic, nonspecific LBP. 40,62,[70][71][72][73] Although the combination of physical and cognitive/behav-ioral treatments in patients with back pain seems not to result in better outcomes when compared to isolated physical or cognitive/behavioral treatments, 74 the inclusion of cognitive/behavioral factors into movement-based classification described by O'Sullivan 25 has shown greater treatment effects when compared to therapies not based on subgrouping (exercise and manual therapy). ...
Article
Background: Treatment for chronic low back pain (LBP) includes different forms of exercises, that to date, have resulted in only small to moderate treatment effects. To enhance the treatment effects, different classification systems have been developed to classify people with LBP into more homogenous subgroups leading to specific treatments for each subgroup. Objective: To compare the efficacy of a treatment based on the Movement System Impairment (MSI) model with a treatment consisting of symptom-guided stretching and strengthening exercises in people with chronic LBP. Design: The study was a two-arm, prospectively registered, randomized controlled trial with a blinded assessor. Setting: The study setting was a university physical therapy clinic in Brazil. Patients: A total of 148 participants with chronic LBP participated in the study. Interventions: Participants were randomly allocated to an 8-week treatment of either treatment based on the MSI-based classification system or symptom-guided stretching and strengthening exercises. Measurements: Measures of pain intensity, disability and global impression of recovery were obtained by a blinded assessor at baseline and at follow-up appointments at two, four and six months after randomization. Results: There were no significant between-group differences for the primary outcomes of pain intensity at two months (mean difference = 0.05, 95% CI = -0.90 to 0.80) and disability at two months (mean difference = 0.00, 95% CI = -1.55 to 1.56). There also were no statistically significant differences between treatment groups for any of the secondary outcome measures. Limitations: Participants and physical therapists were not blinded. Conclusions: People with chronic LBP had similar improvements in pain, disability and global impression of recovery with treatment consisting of symptom-guided stretching and strengthening exercises and treatment based on the MSI model.
... Current clinical research suggests patients with NSLBP demonstrate different clinical characteristics that may result from different underlying contributory mechanisms [5][6][7][8][9]. Impairment in inter-segmental movement coordination (e.g., coordination between the lumbar spine, pelvis and hip) has been proposed as one cause of NSLBP [8,10]. ...
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Background Clinical observation of aberrant movement patterns during active forward bending is one criterion used to identify patients with non-specific low back pain suspected to have movement coordination impairment. The purpose of this study was to describe and quantify kinematic patterns of the pelvis and trunk using a dynamics systems approach, and determine agreement between clinical observation and kinematic classification. Method Ninety-eight subjects performed repeated forward bending with clinical observation and kinematic data simultaneously collected. Kinematic data were plotted using angle-angle, coupling-angle, and phase-plane diagrams. Accuracy statistics in conjunction with receiver operating characteristic curves were used to determine agreement between clinical observation and kinematic patterns. ResultsKinematic patterns were consistent with clinical observation and definitions of typical and aberrant movement patterns with moderate agreement (kappa = 0.46–0.50; PABAK = 0.49–0.73). Early pelvic motion dominance in lumbopelvic coupling-angle diagram ≥59° within the first 38% of the movement represent observed altered lumbopelvic rhythm. Frequent disruptions in lumbar spine velocity represented by phase-plane diagrams with local minimum occurrences ≥6 and sudden decoupling in lumbopelvic coupling-angle diagrams with sum of local minimum and maximum occurrences ≥15 represent observed judder. Conclusion These findings further define observations of movement coordination between the pelvis and lumbar spine for the presence of altered lumbopelvic rhythm and judder. Movement quality of the lumbar spine segment is key to identifying judder. This information will help clinicians better understand and identify aberrant movement patterns in patients with non-specific low back pain.
... Additionally, some studies found reduced strength and endurance (Marshall et al., 2011), as well as increased co-contractions in the gluteus medius muscles (Aghazadeh et al., 2015;Nelson-Wong et al., 2008) in the LBP developer groups. It has also been suggested that neuromuscluar activity of the trunk musculature and kinematics of the lower back contribute to LBP (Behennah et al., 2018;Dankaerts et al., 2007). From a physiological perspective, it might be possible that developing LBP during standing has the same pathological origin as suggested for chronic myalgia in the trapezius muscle. ...
Article
Abstract Low back discomfort (LBD) is common in long-term standing work. The aim of this study was to investigate whether development of LBD during standing is related to lumbar muscle activity and pelvic movement. In a secondary analysis we investigated whether age, gender, and standing work habituation moderates the above-mentioned relationship. Sixty subjects (15 young females, 15 young males, 15 older males, and 15 young males habituated to standing work) were included and had to stand for 4.5 h over three periods with two seated breaks. Surface electromyography, a gravimetrical position sensor, and a numeric rating scale were used to assess lumbar muscle activity, pelvic movement, and LBD, respectively. 22 of 55 analyzed subjects (40%) reported LBD and were assigned to the discomfort developer (DD) group. The remaining subjects (non-discomfort developer: NoDD) showed a statistically significant increase of medio-lateral pelvic movement in the progression of the three standing periods. Almost no differences occurred in lumbar muscle activity (except for the 5th percentile of surface electromyography, which was higher in NoDD). No influence of age, gender, or standing habituation was found. Increased pelvic movement may protect from LBD development during prolonged standing, although differences are very small and clinical relevance is unclear.
... One potential reason for the substantial variation in physical therapy utilization for individuals with LBP may be the inherent heterogeneity of patients presenting with this condition. While the specific number of physical therapy visits would, ideally, vary according to the needs of each individual patient, it may be beneficial to identify smaller cohorts of patients that respond favorably to certain interventions (Dankaerts, O'Sullivan, Burnett, and Straker, 2007;Dankaerts et al., 2006). It has been a research priority to subgroup patients with LBP into more homogenous groups, which may assist in the selection of treatment interventions, help predict chronicity, and attempt to identify patients earlier who may be at increased risk for developing fear avoidance and pain catastrophizing behaviors (Dankaerts et al., 2009;Fritz, Cleland, and Childs, 2007;Fritz, Delitto, and Erhard, 2003;Hall, McIntosh, and Boyle, 2009). ...
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Aim: Currently there is a large and perhaps unwarranted variation regarding physical therapy utilization for individuals with low back pain (LBP). The purpose of this systematic review was to compare the effects of minimal physical therapy utilization/education (two visits or less) versus typical physical therapy utilization (three visits or more) on patient-important outcomes for patients with LBP. Methods: Two independent reviewers searched Cochrane, Medline, CINAHL, Web of Science, and PEDro from database inception until March 2017. Eligible studies used a randomized design, included subjects with LBP, and compared minimal versus higher utilization. The GRADE approach was used to provide an overall level of evidence regarding utilization. Eight articles (1153 individual subjects) met the inclusion criteria. Effect sizes for each outcome measure were calculated using Hedge’s g and were adjusted for baseline values at each time period. Findings: When compared with minimal utilization, higher utilization demonstrated no significant differences on pain, disability, or quality of life at the 1-year follow-up. However, two of the three studies that analyzed cost-effectiveness found higher utilization to be more cost-effective at 1-year follow-up. Moreover, there was insufficient evidence available to investigate patient subgroups (acuity, risk for chronicity), multiple levels of utilization dosage (low, typical, and high), or intervention type. Conclusions: This review identifies the need for further research on the dosage of physical therapy among various subgroups of patients with LBP. While higher utilization may not result in significant improvements in patient-important outcomes, it may be more cost-effective for patients with chronic or complex LBP conditions when compared to minimal utilization.
... Different classification systems of patients with nonspecific low back pain (NSLBP) have identified various impaired movement patterns of the lumbopelvic region that have been labelled in a variety of ways (Ann Flavell et al. 2014;Spoto and Dixon 2015). These impairments are: uncontrolled movements (Comerford and Mottram 2012), movement impairments (Sahrmann 2002;Sahrmann et al. 2017), or motor control impairments (Dankaerts et al. 2007;Denteneer et al. 2017;O'Sullivan 2005). Recent reports have determined that the evaluation of control impairment (CI) of the lumbopelvic region in the presence of LBP has a greater diagnostic discrimination when the movement is identified in more than one plane (i.e. ...
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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.
Article
Objective: To identify differences in repositioning error in adolescents with and without non-specific chronic low back pain (NSCLBP), sub-groups of NSCLBP and in different spinal regions. Methods: Spinal repositioning error was measured during a seated task. Variables were constant error (CE), absolute error (AE) and variable error (VE) for lower lumbar, upper lumbar and lumbar angles. 28 subjects with NSCLBP were sub-classified using O'Sullivans system and compared to 28 healthy controls. Results: Significant differences were noted for AE between adolescents with and without NSCLBP, but no differences were found for CE or VE. When sub-grouped there was a pattern for lower AE and higher VE in the flexion sub-group. This group also displayed a tendency to undershoot the criterion position in the lower lumbar spine. Greater VE was noted in the extension sub-group and those with no NSCLBP in the upper lumbar compared to the lower lumbar spine. Conclusions: Differences in spinal repositioning errors were noted between adolescents with and without NSCLBP and sub-groups of NSCLBP. Those with flexion-pattern NSCLBP had the lowest levels of spinal repositioning ability. Individuals with no-LBP (low-back pain) or extension-pattern NSCLBP displayed greater variability in the upper lumbar spine.
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Study Design. Pragmatic randomized controlled single-blinded study. Objective. To compare the effects of the classifi cation system guided postural intervention (CSPI) with generalized postural intervention (GPI) in subgroups of nonspecifi c chronic low back pain (NSCLBP). Summary of Background Data. Spinal motor control impairments and the associated alterations in spinal postures adopted by patients with NSCLBP are highly variable. Research evaluating the effect of interventions that target the specifi c movement/posture impairments in NSCLBP subgroups is therefore warranted. Methods. A total of 49 patients with NSCLBP with a classifi cation of fl exion pattern (n = 29) and active extension pattern (n = 20) control impairment were recruited from a large cohort study and randomly assigned into CSPI and GPI. The primary outcome was change in Roland-Morris Disability Questionnaire, secondary outcomes were change in pain visual analogue scale, spinal repositioning sense including thoracic and lumbar absolute error, variable error, constant error, and trunk muscle activity during sitting and standing. The intervention was evaluated at baseline, immediately post oneto- one intervention and post 4-week home-based training. Results. The CSPI produced statistically and clinically signifi cant reduction in disability (4.2 [95% CI, 2.9–5.3]) and pain (2, [95% CI1.3–2.6]) compared with minimal change in the GPI disability (0.4, [95% CI, − 0.8 to 1.6]) and pain ( − 0.2, [95% CI, − 0.5 to 0.9]). Repeated measures analysis of variance revealed that CSPI signifi cantly reduced absolute error in thoracic (sitting) and lumbar spine (standing) and constant error in lumbar spine (standing) post one-to-one phase, although this was no longer signifi cant at 4 weeks. Neither intervention had an effect on trunk muscle activity. Conclusion. Compared with minimal change in the GPI group, the CSPI produced statistically and clinically signifi cant improvements in disability and pain outcomes and short-term improvements in some parameters of spinal repositioning sense in NSCLBP subgroups. Key words: nonspecifi c chronic low back pain , classifi cationguided intervention , posture , RMDQ , VAS , thoracic and lumbar repositioning error , spinal wheel , sEMG . Level of Evidence: 2 Spine 2013;38:1613–1625
Article
Studies examining repositioning error (RE) in non-specific chronic low back pain (NSCLBP) demonstrate contradictory results, with most studies not correlating RE deficits with measures of pain, disability or fear. This study examined if RE deficits exist among a subgroup of patients with NSCLBP whose symptoms are provoked by flexion, and how such deficits relate to measures of pain, disability, fear-avoidance and kinesiophobia. 15 patients with NSCLBP were matched (age, gender, and body mass index) with 15 painfree participants. Lumbo-pelvic RE, pain, functional disability, fear-avoidance and kinesiophobia were evaluated. Participants were asked to reproduce a target position (neutral lumbo-pelvic posture) after 5 s of slump sitting. RE in each group was compared by evaluating constant error (CE), absolute error (AE) and variable error (VE). Both AE (p = 0.002) and CE (p = 0.006) were significantly larger in the NSCLBP group, unlike VE (p = 0.165) which did not differ between the groups. There were significant, moderate correlations in the NSCLBP group between AE and functional disability (r = 0.601, p = 0.018), and between CE and fear-avoidance (r = -0.577, p = 0.0024), but all other correlations were weak (r < 0.337, rs < 0.377) or non-significant (p > 0.05). The results demonstrate increased lumbo-pelvic RE in a subgroup of NSCLBP patients, with the selected subgroup undershooting the target position. Overall, RE was only weakly to moderately correlated with measures of pain, disability or fear. The deficits observed are consistent with findings of altered motor control in patients with NSCLBP. The mechanisms underlying these RE deficits, and the most effective method of addressing these deficits, require further study.
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Achtergrond: Myotone dystrofie(MD) is de meest voorkomende musculaire dystrofie. Kenmerkend is een vertraagd ontspannen van de aangespannen musculatuur. Dit leidt vaak tot musculoskeletale en sociale problematiek. Er is geen onderzoek gedaan naar de relatie tussen MD en rugklachten en welke rol manuele therapie hierin speelt. Methode: 61-jarige dame met MD, motor control impairment (MCI) en aspecifieke lage rugklachten: 6-WMT 33% van de norm, RAND-36 scoort 41/100, QBPDS 50/100, NRS(pijn)gem=70, MRC 3/5 wordt behandeld met HVT, mobilisaties en actieve oefentherapie. Resultaten: NRS is significant gedaald met 3 punten. QBPDS 51/100, 6-WMT naar 23%, RAND-36 naar 50/100, MRC naar 4/5. Conclusie: Manuele therapie in ruime zin levert een positieve bijdrage aan de Motor Control(MC) en afname van de pijn maar niet aan de kwaliteit van leven (KvL) en beperking van activiteiten van een patiënt met MD en aspecifieke lage rugpijn. Verder onderzoek is gewenst om de relatie tussen MD en aspecifieke lage rug vast te stellen en RCT’s zijn gewenst om de effectiviteit van manuele therapie bij deze groep verder te onderzoeken.
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This study compared regional lumbar (upper and lower), pelvis, trunk and lower limb kinematics between elite male adolescent players with and without a history of LBP during the kick and flat serves, as well as regional lumbar mobility and serving kinematics relative to end range. Seven players with a history of LBP and confirmed L4/L5 injury and 13 controls matched for age, height, mass and performance underwent three-dimensional motion analysis during serving trials and lumbar mobility assessments. Regional lumbar, pelvis, trunk and lower limb kinematics were compared between pain/no pain and kick/flat serves using a series of 2x2 mixed model analyses of variance, with independent samples t-tests utilised to compare regional lumbar mobility between pain/no pain. The pain group had significantly reduced lower lumbar mobility in every plane of motion than the no pain group. The pain group demonstrated less right lower lumbar and pelvis/shoulder rotation, greater right pelvic tilt, and earlier peak right knee extension velocity during the drive phase of the tennis serves, and greater lower lumbar and pelvis left rotation, upper lumbar left lateral flexion and anterior pelvis tilt during the forward swing phase. All players approached their lumbar end of range during the serve. The results of this investigation suggest that a multi-dimensional LBP management and prevention strategy is required, including; assessment of regional spinal mobility, lower limb and upper limb and spinal kinematics, and integrated work between clinicians and coaches to adapt adverse technique.
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Study design: Case report. Background: Contemporary low back pain models propose that the experience of and responses to pain result from a complex interaction of biopsychosocial factors. This supports the need for a management approach that addresses the biological, psychological, and social components that may be related to the pain disorder. This case report demonstrates the application of, and outcomes associated with, a cognitive functional intervention that considers neurophysiological, physical, psychosocial, cognitive, and lifestyle dimensions for the management of a rower with nonspecific chronic low back pain. Case description: An adolescent male club-level rower with nonspecific chronic low back pain was classified as having a motor control impairment with a lower lumbar compressive-loading pattern in flexion. Evaluation of this patient included ergometer rowing analysis (clinical and laboratory) before and after an 8-week intervention, and outcome measures at a 12-week follow-up. The intervention consisted of a cognitive functional approach that targeted optimization of movement behavior, providing the rower with alternative movement strategies to minimize sustained flexion loading. Outcomes: Reduced temporal summation of pain while ergometer rowing and reduced functional disability were observed preintervention to 12 weeks postintervention by changes in Roland-Morris Disability Questionnaire score (12/24 to 1/24) and the Patient-Specific Functional Scale (4/30 to 26/30), and associated improvements in lower-limb and back muscle endurance and changes in hip and spinopelvic kinematics during ergometer rowing. In particular, there was a greater use of available range of movement in the lumbar spine postintervention. Discussion: The cognitive functional intervention for this patient resulted in reduced pain and functional disability related to ergometer rowing, which was associated with a change in lumbar kinematics and improved lower-limb and back muscle endurance. The results suggest that providing the rower with greater use of his available range of movement may enhance load distribution during the drive phase of rowing. Registered at Australian New Zealand Clinical Trials Registry (ACTRN12609000565246). Level of evidence: Therapy, level 4.
Article
Background: Telehealth evaluations of musculoskeletal conditions have increased due to the stay-at-home policies enacted during the COVID-19 pandemic. Back pain is one of the most common complaints in primary care. While telehealth may never supplant in-person evaluation of back pain, it is imperative in a changing world to learn to perform this evaluation via telephone or video. Virtual visits rely on history-taking and patient self-reported descriptions of pain elicited from self-palpation or specific movements while on the telephone with the clinician. Video examinations provide a unique way of evaluating the lower back compared to telephone because of the ability to visualize the actions of the patient. Objective: To create an evaluation pathway for examination of the lumbar spine via telehealth. Methods: Our group has created a step-by-step evaluation pathway to help physicians direct their patients through typical lumbar examination elements, including inspection, palpation, range of motion, and strength, special, and functional testing. Results: We have developed a table of questions and instructions and a glossary of images of each maneuver to facilitate lumbar spine examination via telemedicine. Conclusions: This paper provides a guide for extracting clinically relevant information while performing telemedicine examinations of the lumbar spine.
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Non-specific chronic low back pain (NSCLBP) is a very common and costly musculoskeletal disorder associated with a complex interplay of biopsychosocial factors. Cognitive functional therapy (CFT) represents a novel, patient-centred intervention which directly challenges pain-related behaviours in a cognitively integrated, functionally specific and graduated manner. CFT aims to target all biopsychosocial factors that are deemed to be barriers to recovery for an individual patient with NSCLBP. A recent randomised controlled trial (RCT) demonstrated the superiority of individualised CFT for NSCLBP compared to manual therapy combined with exercise. However, several previous RCTs have suggested that class-based interventions are as effective as individualised interventions. Therefore, it is important to examine whether an individualised intervention, such as CFT, demonstrates clinical effectiveness compared to a relatively cheaper exercise and education class. The current study will compare the clinical effectiveness of individualised CFT with a combined exercise and pain education class in people with NSCLBP. This study is a multicentre RCT. 214 participants, aged 18-75 years, with NSCLBP for at least 6 months will be randomised to one of two interventions across three sites. The experimental group will receive individualised CFT and the length of the intervention will be varied in a pragmatic manner based on the clinical progression of participants. The control group will attend six classes which will be provided over a period of 6-8 weeks. Participants will be assessed preintervention, postintervention and after 6 and12 months. The primary outcomes will be functional disability and pain intensity. Non-specific predictors, moderators and mediators of outcome will also be analysed. Ethical approval has been obtained from the Mayo General Hospital Research Ethics Committee (MGH-14-UL). Outcomes will be disseminated through publication according to the SPIRIT statement and will be presented at scientific conferences. (ClinicalTrials.gov NCT02145728). Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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The purpose of this study was to identify how activity patterns of trunk muscles change in chronic LBP during walking. Type A systematic review Literature survey ELSEVIER, Pro Quest, PubMed, Google scholar and MEDLINE electronic databases were explored for the earliest researchable time to August 2014 period. Articles investigating patients with chronic LBP and analyzing trunk muscles with surface electromyography (EMG) during walking were included. ology: All studies had a case-control design. Characteristics of the LBP patients, sample size, studied muscles and EMG parameters, gait condition and velocity were investigated. Studies were rated as "A" to "E" (five grades defined) based on study design and performance. Multifidus (MF), erector spinae (ES), external oblique (EO) and rectus abdominus (RA) muscles activity level were found to be increased in LBP subjects in comparison with controls. ES activity in low back pain subjects was found not to be so adaptive to walking velocity alterations such as in healthy controls. Chronic LBP subjects exhibit higher global trunk muscles activity. However, the activation pattern appears to vary depending on sub-phases of gait. It seems that increased walking velocity challenges the stability of the spine and the control system increases muscular activation and variability level to cope with this problem. Further standardized studies with sub-typed LBP cases are needed to clarify the controversial findings. Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
Article
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Multiple dimensions across the biopsychosocial spectrum are relevant in the management of non-specific chronic low back pain (NSCLBP). Cognitive functional therapy is a behaviourally targeted intervention which combines normalisation of movement and abolition of pain behaviours with cognitive reconceptualisation of the NSCLBP problem, while also targeting psychosocial and lifestyle barriers to recovery. To examine the effectiveness of cognitive functional therapy for people with disabling NSCLBP who are awaiting an appointment with a specialist medical consultant. A multiple case (n=26) cohort study consisting of 3 phases (A1-B-A2). Measurement phase A1 was a baseline phase during which pain and functional disability were collected on three occasions over three months for all participants. During phase B, participants entered a cognitive functional therapy intervention program, involving approximately eight treatments over an average of 12 weeks. Finally, phase A2 was a 12 month no-treatment follow-up period. Outcomes were analysed using repeated measures ANOVA or Friedman's test (with post-hoc Bonferroni) across seven time intervals, depending on normality of data distribution. Statistically significant improvements in both functional disability (p<0.001) and pain (p<0.001) were observed immediately post-intervention, and maintained over the 12 months follow-up period. These reductions reached clinical significance for both disability and pain. Secondary psychosocial outcomes were significantly (p<0.01) improved after the intervention, including depression, anxiety, back beliefs, fear of physical activity, catastrophising and self-efficacy. Not a randomised controlled trial. While primary outcome data was self-reported, the assessor was not blinded. These promising results suggest that cognitive functional therapy should be compared to other conservative interventions for the management of disabling NSCLBP in secondary care settings in large randomised clinical trials. © 2015 American Physical Therapy Association.
Research
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BACKGROUND: Low back pain is a common problem. Pain is always subjective and influenced by physiological, cognitive, and social factors. Up to 30% of low back pain (LBP) patients are estimated to have an uncontrolled lumbar movement. Restoration of neuromuscular control in lumbar back is motor learning. Evidence suggests the use of social cognitive learning theory in chronic pain rehabilitation. According to the learning theory the instructor in motor skill education is recommended to aim at changing the learners mental and skill models and developing the problem-solving skills. Multiple informational sources are needed, e.g. observational learning and understanding of the instructed facts. So far the value of patients own understanding of the problem might be underestimated. PURPOSE: The purpose of this development task was to assess, does the patients identify the uncontrolled movement of the low back, and does the neuromuscular control recover between the physiotherapy visits. Within the task, there was also a purpose to assess, which factors did progress the therapeutic exercise most in the patients perspective. METHODS: Four (N=4) patients of working age (29-61-year-old) participated in this feasibility study. Their lumbar movement control was diagnosed with the movement control tests and patient education and guiding were examined subjectively in two physiotherapy visits. Their comprehension about an uncontrolled lumbar movement, physiotherapist guiding, and factors affecting therapeutic exercises were surveyed with the aid of enquiry and interview forms. RESULTS: Patients differentiated uncontrolled lumbar movement from controlled movement fairly well (avg. 68%) from pictures . Patients identified their own uncontrolled lumbar movement poorly (36%) and they had very different conceptions about the meaning of uncontrolled lumbar movement. On average the controlling of the lumbar movement improved 17% (40%  57%) during the 86 days. All patients experienced that the physiotherapy guidance was the most advancing factor in executing the therapeutic exercises. CONCLUSION: Patients’ uncontrolled lumbar movement got better although they didn't recognize the uncontrolled lumbar movement or its direction correctly. Therapeutic guidance was experienced important by patients, which is in line with previous studies. This study shows that the patients need the physiotherapist guiding in hope of restoring the movement control of lumbar spine. IMPLICATIONS: Study suggests to assess the instructed facts. It also shows the need for improving the dialogue between the patient and the instructor in order to help patient’s understanding of guiding. Interventions are needed to improve patients observational learning in lumbar movement control e.g. by converting modeled activity into codes that symbolize it.
Chapter
Vertebral Metrics is a non-invasive system that was designed to study the biomechanical changes of the spine. Through the identification of the tridimensional position of the vertex of the spinal processes it is able to provide a 3D recon- struction of the spinal column, in the standing position. Studies with the two previous prototypes indicated that the equipment is reliable and has sufficient accuracy for the global evaluation of the spinal column, however, the required time for data collection is too long. Because of that the further development of the system has become necessary. The required steps to develop a new prototype are presented in this work. Before each scan a fluorescent dye will be used to identify the spinal processes above the skin. During a complete scan, the im- proved device will move upwards while is recording a video of the back. Once finished the video recording, image processing algorithms will be applied to recognize the fluorescent marks in the skin. The stereo vision method will be used to determine the spatial position of each mark. Preliminary tests were al- ready performed using the improved system. Results are en- couraging.
Thesis
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L’instabilità vertebrale può dipendere da variazione anatomica, degenerativa, da esiti di interventi chirurgici, dalla mancanza di un adeguato controllo motorio da parte dei muscoli stabilizzatori lombari, si può quindi suddividere l’instabilità vertebrale in anatomica, riscontrabile con la diagnostica per immagini e in clinica o funzionale, ed è proprio a questo tipo di instabilità che è rivolto questo lavoro con l’obiettivo di analizzare da prima un breve accenno alla storia di questa condizione patologica e dopo le evidenze scientifiche più attuali sulla valutazione e sul trattamento dell’instabilità funzionale del rachide lombare, se è stato possibile riuscire ad identificarla come un’entità ben specifica e classificarla come un sottogruppo di lombalgia, con sintomi e segni clinici precisi; avere la possibilità di individuare questo sottogruppo diviene fondamentale per la corretta impostazione del trattamento. L’instabilità clinica viene definita come una “significativa diminuzione della capacità del sistema stabilizzatore a mantenere la zona neutra vertebrale nei limiti fisiologici”. Questo può sviluppare una perdita di stabilità funzionale che può tradursi in dolore e disabilità. La ricerca ha evidenziato che vari elementi dell’esame clinico e alcuni dati anamnestici (come: età dei soggetti, comportamento del dolore, paura del movimento, etc.) sono utili per predire un’instabilità lombare funzionale. Altri test e segni clinici sono: prone instability test, posterior Shear Test, valutazione clinica della lassità legamento generalizzata, arco doloroso in flessione o nel ritorno dalla flessione, Gower sign, la presenza di accelerazione o decelerazione nel movimento del tronco, etc..Gli autori ritengono la presenza di un di questi item un buon indicatore di instabilità vertebrale. L’affidabilità inter-esaminatore di questi test osservazionali però presi singolarmente varia da bassa a moderata. Alcuni autori propongono test specifici per individuare la corretta attivazione e la strategia migliore dei muscoli stabilizzatori lombari. Questi test valutano manualmente e visivamente la presenza e la qualità dell’attivazione muscolare. Nonostante molto utilizzati, non ci sono evidenze che ne determino l’affidabilità. Dall’analisi della letteratura sembra evidenziarsi il bisogno di classificare l’instabilità clinica o funzionale come un sottogruppo di lombalgie delle cosiddette “non-specific lbp”, correlate soprattutto alla chronic lbp, ma la ricerca deve evidenziare ancora questo aspetto diagnostico-valutativo. L’obiettivo prioritario nel trattamento del paziente con instabilità funzionale lombare sembra essere di tipo conservativo e mirato innanzitutto al ripristino del controllo motorio e al training del “Core stability”, anche se esiste il bisogno di ulteriore ricerca in questa area.
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Introduction: A volitional preemptive abdominal contraction (VPAC) supports trunk stability during functional activity. Pain-free individuals can sustain VPAC during function, but such has not been reported for individuals with current low back pain (cLBP). The purposes of this study were to examine whether cLBP affects VPAC performance during a loaded functional-reach (LFR) activity. Methods: A crossover mixed design examined the effects of the LFR activity (with 4.6kg load) and VPAC using the abdominal drawing-in maneuver (ADIM) on TrA activation. Setting was in a laboratory. Participants were 18 Controls and 17 cLBP subjects with pain ratings of 1-7/10. Interventions were blinded TrA thickness measurements were recorded from M-mode ultrasound imaging during 4 conditions: (1) Quiet standing (QS) without ADIM; (2) QS with ADIM; (3) LFR without ADIM; and (4) LFR with ADIM. A physical therapist with 29 years of experience collected historical and examination data. Main Outcome Measures were TrA muscle thickness (mm) representing muscle activation and selected examination data. Results: A 2(Group) x 2(Contraction) x 2(Reach) Analysis of Variance (ANOVA) demonstrated a significant Group x Contraction interaction [F (1, 31) = 4.499, p = 0.042]; ADIM produced greater TrA thickness increases in PLBP subjects (2.18mm) versus Controls (1.36mm). We observed a significant main effect for Reach [F (1, 31) = 14.989, p = 0.001]. The LFR activity produced a greater TrA thickness (6.15 ± 2.48mm) versus quiet standing (5.30 ± 2.12mm). Conclusions: While subjects with cLBP demonstrated slightly less abdominal activation during every condition, they exhibit a greater increase in TrA activation during ADIM versus controls. Individuals can utilize the ADIM strategy as a protective VPAC response during a LFR.
Poster
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We compared the functional movement impairments in individuals with and without low back pain, and examined their association with the active straight leg raise, as the most common evaluation test for low back pain.
Article
Study design: A pilot, two-group pretest-posttest randomized controlled, single blinded study. Objective: Our study aim was to compare the changes in low back pain level, fear avoidance, neurodynamic mobility, and function after early versus later exercise intervention following a unilateral lumbar microdiscectomy. Summary of background data: Exercise is commonly recommended to patients following a lumbar microdiscectomy although controversy remains as to the timing and protocols for exercise intervention. Methods: Forty patients were randomly allocated to early (Group 1) or later (Group 2) exercise intervention group. The low back pain and fear avoidance were evaluated using Oswestry Low Back Pain Disability Questionnaire, Numeric Pain Rating Scale, and Fear-Avoidance Beliefs Questionnaire. The neurodynamic mobility and function were recorded with Dualer Pro IQ Inclinometer, 50-foot walk test, and Patient-Specific Functional Scale. Two-sided t test for continuous variables and chi-square or Fisher exact test for categorical variables were used to compare the two groups' demographic data. The Wilcoxon signed-rank and rank-sum tests were used to compare the changes and the differences, respectively, in low back pain, fear avoidance, neurodynamic mobility, and function between baseline (before surgery) and postoperative repeated measurements (at 1-2, 4-6, and 8-10 wks after surgery) within each study group, after exercise intervention. Results: Both groups showed a significant decrease in low back pain levels and fear avoidance as well as a significant improvement in neurodynamic mobility and function at 4 and 8 weeks after surgery. However, no significant difference was reported between the two groups. Conclusion: Our study results showed that early exercise intervention after lumbar microdiscectomy is safe and may reduce the low back pain, decrease fear avoidance, and improve neurodynamic mobility and function. A randomized controlled trial is needed to evaluate the early exercise intervention's effectiveness after lumbar microdiscectomy, and thus validate our findings.Level of Evidence: 4.
Data
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There is a large variety of criteria and tests that can be used to determine clinical lumbar instability (CLI). The current trend is to use a cluster of tests. A number of specific tests can be used to determine the 'working diagnosis' clinical lumbar instability. According to earlier performed studies, there is no clear definition of clinical lumbar instability. Panjabi stated that some patients with clinical lumbar instability show motor control impairments. Lack of control of the lumbar segments can reduce the stability which can not be compensated and which in turn can lead to complaints. The most important symptoms are: varying low back pain and increase of symptoms during prolonged sitting which can lead to radiating pain in the legs. AUTHORS Huub Vossen, MMT, editor in chief of the Dutch Association of Manual Therapy (NVMT). Katrien Bartholomeeusen, MSc, tutor in manual therapy at SOMT and University at Gent. Paul Huisman, MSc, private praxis in manual therapy This study was nominated for the EPR-price* in 2008. *European Platform for Rehabilitation at Brussel, Belgium.
Article
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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.
Article
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The neutral zone is a region of intervertebral motion around the neutral posture where little resistance is offered by the passive spinal column. Several studies--in vitro cadaveric, in vivo animal, and mathematical simulations--have shown that the neutral zone is a parameter that correlates well with other parameters indicative of instability of the spinal system. It has been found to increase with injury, and possibly with degeneration, to decrease with muscle force increase across the spanned level, and also to decrease with instrumented spinal fixation. In most of these studies, the change in the neutral zone was found to be more sensitive than the change in the corresponding range of motion. The neutral zone appears to be a clinically important measure of spinal stability function. It may increase with injury to the spinal column or with weakness of the muscles, which in turn may result in spinal instability or a low-back problem. It may decrease, and may be brought within the physiological limits, by osteophyte formation, surgical fixation/fusion, and muscle strengthening. The spinal stabilizing system adjusts so that the neutral zone remains within certain physiological thresholds to avoid clinical instability.
Article
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Presented here is the conceptual basis for the assertion that the spinal stabilizing system consists of three subsystems. The vertebrae, discs, and ligaments constitute the passive subsystem. All muscles and tendons surrounding the spinal column that can apply forces to the spinal column constitute the active subsystem. The nerves and central nervous system comprise the neural subsystem, which determines the requirements for spinal stability by monitoring the various transducer signals, and directs the active subsystem to provide the needed stability. A dysfunction of a component of any one of the subsystems may lead to one or more of the following three possibilities: (a) an immediate response from other subsystems to successfully compensate, (b) a long-term adaptation response of one or more subsystems, and (c) an injury to one or more components of any subsystem. It is conceptualized that the first response results in normal function, the second results in normal function but with an altered spinal stabilizing system, and the third leads to overall system dysfunction, producing, for example, low back pain. In situations where additional loads or complex postures are anticipated, the neural control unit may alter the muscle recruitment strategy, with the temporary goal of enhancing the spine stability beyond the normal requirements.
Article
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A survey of expert orthopedic physical therapists was conducted to assist in the development of a classification system for patients with low back pain (LBP). The goal of the survey was to measure levels of agreement on labels and accompanying constellations of signs and symptoms for subgroups of patients with LBP. Twenty-four of the 30 expert orthopedic physical therapists who were originally contacted responded to the survey request. A modified Delphi technique was used. The first stage involved a review of the literature and identification of 25 diagnostic classes of LBP. Experts were asked to rate the "appropriateness" of each diagnostic class for inclusion in a classification scheme. Clinical findings relevant to each diagnostic class were identified and rated on the degree of "essentialness" to that class. Three diagnostic classes--hypomobility dysfunction, nerve root adhesion, and sacroiliac hypermobility--were distinct in that the agreement criteria for the appropriateness of diagnostic classes as well as the surveyed essential signs and symptoms were met. Six of the 25 diagnostic classes did not meet the minimum levels required for agreement as appropriate diagnostic classes: facet syndrome, chronic pain behavior, muscle strain, iliolumbar ligament sprain, posterior ligament sprain, and myofascial dysfunction. The importance of developing homogeneous subgroups of patients with LBP based on constellations of reliable clinical findings is emphasized.
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To investigate the claim that 90% of episodes of low back pain that present to general practice have resolved within one month. Prospective study of all adults consulting in general practice because of low back pain over 12 months with follow up at 1 week, 3 months, and 12 months after consultation. Two general practices in south Manchester. 490 subjects (203 men, 287 women) aged 18-75 years. Proportion of patients who have ceased to consult with low back pain after 3 months; proportion of patients who are free of pain and back related disability at 3 and 12 months. Annual cumulative consultation rate among adults in the practices was 6.4%. Of the 463 patients who consulted with a new episode of low back pain, 275 (59%) had only a single consultation, and 150 (32%) had repeat consultations confined to the 3 months after initial consultation. However, of those interviewed at 3 and 12 months follow up, only 39/188 (21%) and 42/170 (25%) respectively had completely recovered in terms of pain and disability. The results are consistent with the interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months. However most will still be experiencing low back pain and related disability one year after consultation.
Article
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The purpose of this study was to examine the interrater reliability of measurements obtained by examiners administering tests proposed to be important for classifying low back pain (LBP) problems. Ninety-five subjects with LBP (41 men, 54 women) and 43 subjects without LBP (17 men, 26 women) were examined by 5 therapists trained in the techniques used. A manual was developed by the first author that described the clinical examination procedures. The therapists were trained by the first author in the test procedures and definitions. The training included instruction through videotapes, practice and a written examination. Each examination was conducted by a pair of therapists. Within a pair, a therapist was the primary examiner for half of the subjects and an observer was the primary examiner for half of the subjects. Examination findings were recorded independently, without discussion. Percentage of agreement and generalized kappa coefficients were used to analyzed the data. Kappa values were > or = .75 for all 28 items related to the symptoms elicited and > or = .40 for 72% of the 25 items related to alignment and movement. The results suggest that experienced therapist who had trained together were able to agree on the results of examinations and obtain an acceptable level of reliability. Future work should focus on testing of reliability when more than one therapist performs the examination and when therapist not trained by the test developer to administer the examination perform the tests. [Van Dillen LR, Sahrmann SA, Norton BJ, et al. Reliability of physical examination items used for classification of patients with low back pain.
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Despite the widespread use of traction, little is known of the mode of effect, and application remains largely anecdotal. The efficacy of traction is also unclear because of generally poor design of the clinical trials to date, and because subgroups of patients most likely to benefit have not been specifically studied. These observations prompted this review, the purposes of which are to evaluate the mechanisms by which traction may provide benefit and to provide rational guidelines for the clinical application of traction. Traction has been shown to separate the vertebrae and it appears that large forces are not required. Vertebral separation could provide relief from radicular symptoms by removing direct pressure or contact forces from sensitised neural tissue. Other mechanisms proposed to explain the effects of traction (e.g. reduction of disc protrusion or altered intradiscal pressure) have been shown not to occur. We conclude that traction is most likely to benefit patients with acute (less than 6 weeks' duration) radicular pain with concomitant neurological deficit. The apparent lack of a dose-response relationship suggests that low doses are probably sufficient to achieve benefit.
Article
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This case report describes the use of a classification system in the evaluation of a patient with chronic low back pain (LBP) and illustrates how this system was used to develop a management program in which the patient was instructed in symptom-reducing strategies for positioning and functional movement. The patient was a 55-year-old woman with a medical diagnosis of lumbar degenerative disk and degenerative joint disease from L2 to S1. Rotation with extension of the lumbar spine was found to be consistently associated with an increase in symptoms during the examination. Instruction was provided to restrict lumbar rotation and extension during performance of daily activities. The patient completed 8 physical therapy sessions over a 3-month period. Pretreatment, posttreatment, and 3-month follow-up modified Oswestry Disability Questionnaire scores were 43%, 16%, and 12%, respectively. Daily repetition of similar movements and postures may result in preferential movement of the lumbar spine in a specific direction, which then may contribute to the development, persistence, or recurrence of LBP. Research is needed to determine whether patients with LBP would benefit from training in activity modifications that are specific to the symptom-provoking movements and postures of each individual as identified through examination.
Article
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The aim was to examine lumbar spine kinematics, spinal joint loads and trunk muscle activation patterns during a prolonged (2 h) period of sitting. This information is necessary to assist the ergonomist in designing work where posture variation is possible -- particularly between standing and various styles of sitting. Joint loads were predicted with a highly detailed anatomical biomechanical model (that incorporated 104 muscles, passive ligaments and intervertebral discs), which utilized biological signals of spine posture and muscle electromyograms (EMG) from each trial of each subject. Sitting resulted in significantly higher (p<0.001) low back compressive loads (mean +/- SD 1698 +/- 467 N) than those experienced by the lumbar spine during standing (1076 +/- 243 N). Subjects were equally divided into adopting one of two sitting strategies: a single 'static' or a 'dynamic' multiple posture approach. Within each individual, standing produced a distinctly different spine posture compared with sitting, and standing spine postures did not overlap with flexion postures adopted in sitting when spine postures were averaged across all eight subjects. A rest component (as noted in an amplitude probability distribution function from the EMG) was present for all muscles monitored in both sitting and standing tasks. The upper and lower erector spinae muscle groups exhibited a shifting to higher levels of activation during sitting. There were no clear muscle activation level differences in the individuals who adopted different sitting strategies. Standing appears to be a good rest from sitting given the reduction in passive tissue forces. However, the constant loading with little dynamic movement which characterizes both standing and sitting would provide little rest/change for muscular activation levels or low back loading.
Article
Study Design. Review of advances in the primary care research on low back pain (LBP) from a unique international forum, and analysis of open-ended questionnaires from participants. Summary of Background Data. LBP continues to be one of the most common and challenging problems in primary care. It is associated with enormous costs in terms of direct health care expenditures, and indirect work and disability-related losses. Objective. To ascertain the current status and state of the art regarding LBP in primary care. Methods. Four reviewers independently assessed the content and implications of presentations at the Fourth International Forum for Primary Care Research on LBP, pooled the data, and then augmented it with open-ended questionnaires completed by 35 participants. Results. The Fourth Forum documented the field’s emergent new paradigm–a transition from thinking about back pain as a biomedical “injury” to viewing LBP as a multifactorial biopsychosocial pain syndrome. The paradigm shift has occurred in the context of increased interest in evidence-based medicine regarding LBP in primary care. The Forum demonstrated the strides taken in moving from research and evidence gathering, through guidelines and policy formulations and finally to the dissemination and implementation imperative. There was an increasing confidence among the Forum researchers that LBP can be managed successfully in primary care settings through a combination of encouraging activity, reassurance, short-term symptom control, and alteration of inappropriate beliefs about the correlations of back pain with impairment and disability. There is also recognition that a wide range of international, evidence-based guidelines now exists that have very similar messages. Conclusions. The Fourth Forum reflected a major shift in the conceptualization of LBP in primary care and an increased emphasis on implementation and dissemination of LBP research findings and clinical guidelines. Although there is a wide array of challenges ahead, the Fourth Forum provided a clear message regarding the need to focus research energies on changing practitioner behavior.
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
By manipulation of movement reaction time we investigated the co-ordination between the motor command for arm movement and the associated ‘anticipatory’ postural response of the abdominal muscles. Limb movement reaction time was varied by changing the expectation of limb movement direction required in a choice-reaction-time task. Timing of the ‘anticipatory’ postural contraction of transversus abdominis (TrA) was invariant while the limb movement reaction time varied with changes in expectation of required response. In contrast, the timing of ‘anticipatory’ postural activity of the other abdominal muscles co-varied with limb movement reaction time. Dissociation of the behaviour of TrA and the other abdominal muscles suggests that TrA may be controlled independently of the motor command for limb movement in contrast to the other abdominal muscles.
Article
The aim was to investigate possible relationships between activities of the individual muscles of the ventrolateral abdominal wall and the development of pressure within the abdominal cavity. Intra-muscular activity was recorded bilaterally from transversus abdominis, obliquus internus, obliquus externus and rectus abdominis with fine-wire electrodes guided into place using real-time ultrasound. Intra-abdominal pressure was measured intragastrically using a micro tip pressure transducer. Six males were studied during loading and movement tasks with varied levels of intra-abdominal pressure. During both maximal voluntary isometric trunk flexion and extension, transversus abdominis activity and intra-abdominal pressure remained constant, while all other abdominal muscles showed a marked reduction during extension. When maximal isometric trunk flexor or extensor torques were imposed upon a maximal Valsalva manoeuvre, transversus abdominis activity and intra-abdominal pressure remained comparable within and across conditions, whereas obliquus internus, obliquus externus and rectus abdominis activities either markedly increased (flexion) or decreased (extension). Trunk twisting movements showed reciprocal patterns of activity between the left and right sides of transversus abdominis, indicating an ability for torque development. During trunk flexion--extension, transversus abdominis showed less distinguished changes of activity possibly relating to a general stabilizing function. In varied pulsed Valsalva manoeuvres, changes in peak intra-abdominal pressure were correlated with mean amplitude electromyograms of all abdominal muscles, excluding rectus abdominis. It is concluded that the co-ordinative patterns shown between the muscles of the ventrolateral abdominal wall are task specific based upon demands of movement, torque and stabilization. It appears that transversus abdominis is the abdominal muscle whose activity is most consistently related to changes in intra-abdominal pressure.
Article
The relationship between videotape ratings of pain behavior and the flexion-relaxation phenomenon was evaluated in a sample of 39 chronic low-back pain patients. The results showed that guarded movement explained approximately 27% of the variability in the flexion-relaxation phenomenon, adjusting for pain intensity rating. There were no significant differences in sex observed. It is recommended that clinicians pay close attention to qualitative aspects of patient behavior to improve the sensitivity of the physical examination in detecting bona fide impairment.
Article
Because there is increasing concern about low-back disability and its current medical management, this analysis attempts to construct a new theoretic framework for treatment. Observations of natural history and epidemiology suggest that low-back pain should be a benign, self-limiting condition, that low back-disability as opposed to pain is a relatively recent Western epidemic, and that the role of medicine in that epidemic must be critically examined. The traditional medical model of disease is contrasted with a biopsychosocial model of illness to analyze success and failure in low-back disorders. Studies of the mathematical relationship between the elements of illness in chronic low-back pain suggest that the biopsychosocial concept can be used as an operational model that explains many clinical observations. This model is used to compare rest and active rehabilitation for low-back pain. Rest is the commonest treatment prescribed after analgesics but is based on a doubtful rationale, and there is little evidence of any lasting benefit. There is, however, little doubt about the harmful effects--especially of prolonged bed rest. Conversely, there is no evidence that activity is harmful and, contrary to common belief, it does not necessarily make the pain worse. Experimental studies clearly show that controlled exercises not only restore function, reduce distress and illness behavior, and promote return to work, but actually reduce pain. Clinical studies confirm the value of active rehabilitation in practice. To achieve the goal of treating patients rather than spines, we must approach low-back disability as an illness rather than low-back pain as a purely physical disease. We must distinguish pain as a purely the symptoms and signs of distress and illness behavior from those of physical disease, and nominal from substantive diagnoses. Management must change from a negative philosophy of rest for pain to more active restoration of function. Only a new model and understanding of illness by physicians and patients alike makes real change possible.
Article
Electromyographic activity of erectores spinae exhibits points of abrupt change during trunk flexion from the erect position and return extension. This study examined the positions at which the myoelectric activity suddenly disappeared and later reappeared. Forty adults were investigated to define accurately the inclinations of the trunk, pelvis, and vertebral column at these positions. The positions at the commencement and cessation of the period of electrical silence both occurred at two-thirds of maximum trunk flexion (mean = 80 degrees +/- 13 degrees SD). At these positions, all flexion measurements were significantly less than their maxima (P less than 0.001). Hip flexion at the commencement of electrical silence was slightly above one-half its maximum range, and similar to the position at the recommencement of electrical activity (mean = 40 degrees +/- 12 degrees SD). The most reproducible measurement (r = 0.88) in both positions was vertebral flexion (89% Max.; mean = 48 degrees +/- 6 degrees SD). Eleven of the male subjects repeated the experimental task holding 10.1 kg in their hands. The effect of this was to produce inhibition and reactivation of erectores spinae at a greater degree of vertebral flexion.
Article
At a certain position of trunk flexion, there is a sudden onset of electrical silence in back muscles. This is called "flexion-relaxation (F-R) phenomenon." The goals of this study were (1) to evaluate the relationship between flexion angle and activity of back muscles during flexion movement and (2) to determine what the difference is between healthy subjects and patients with chronic low back pain (CLBP). Twenty-five healthy subjects (13 males and 12 females; average age, 28.3 yr) and 20 patients with CLBP (12 males and 8 females; average age, 34.1 yr) volunteered for this study. The subjects were asked to flex forward maximally from the erect position and to maintain full flexion, followed by returning to the initial upright position. Flexion angle of trunk and hip was measured during the examination. Electromyographic activity of erector spinae was also monitored simultaneously. F-R phenomenon was observed in all healthy subjects before reaching the maximum flexion. Electrical silence continued even after extending the trunk began. In contrast, no patients with CLBP demonstrated F-R phenomenon. A significant difference in muscular activities of erector spinae between the groups was obtained when returning to the erect position from the maximum flexion. Moreover, time lag between trunk and hip movement was much greater in patients than in healthy subjects. This study demonstrated that neuromuscular coordination between trunk and hip could be abnormal in patients with CLBP.
Article
This study used an anatomically detailed model of the lumbar tissues, driven from biologic signals of vertebral displacement and myoelectric signals, to estimate individual muscle and passive tissue force-time histories during the performance of the "flexion-relaxation" maneuver. Eight male university students performed three trials each of the "flexion-relaxation" maneuver with six pairs of surface myoelectric electrodes monitoring the right side of the trunk musculature, an electromagnetic device to record lumbar flexion, and videotape to record body segment displacement. To examine the loads on individual tissues during the transfer of moment support responsibility from predominantly active muscle to predominantly passive tissue. No previous studies, to the authors' knowledge, have examined individual tissue loading during the flexion-relaxation maneuver. Although most subjects were able to "relax" their lumbar extensors in full flexion, activity remained in the thoracic extensors and abdominals. Tissue load predictions suggested that while the lumbar extensor muscles were neurally "relaxed" (i.e., myoelectric silence), substantial elastic forces would assist the passive tissues in extensor moment support. On average, subjects sustained almost 3 kN in compressive load on the lumbar spine and about 755 N of anterior shear during full flexion with only 8 kg held in the hands. The "relaxation" of lumbar extensor muscles appeared to occur only in an electrical sense because they generated substantial force elastically through stretching. Loading of the interspinous and supraspinous ligaments, in particular, was high relative to their failure tolerance.
Article
This study examines the reliability and validity of measuring lumbar range of motion with an inclinometer. To find out whether a manual determination of the reference points for measuring lumbar range of motion is as reliable as radiologic determination for positioning the inclinometers, lumbar range of motion was determined in degrees by evaluating radiographs and by using the inclinometer technique of Loebl. Reliability and validity of the inclinometer technique as a clinical measurement of trunk flexibility were investigated. Fifty-four patients participated in the study. Lumbar range of motion measurements were taken with and without radiologic control of the T12 and S1 vertebrae as reference points for positioning of the inclinometers. An interrater correlation was done of the inclinometer techniques of a physician and a physiotherapist. Functional radiographs were investigated in a standing position. Lumbar range of motion measurements based on radiographs and those taken using the inclinometer alone were correlated to validate the inclinometer technique. Lumbar range of motion measurements taken with and without radiologic determination showed a very close correlation (r = 0.93; P < 0.001). Flexion alone also demonstrated a close correlation (r = 0.95; P < 0.001), whereas extension showed a somewhat smaller correlation (r = 0.82; P < 0.001). Total lumbar range of motion (r = 0.94; P < 0.001) and flexion (r = 0.88; P < 0.001) were closely related, as indicated by the interrater correlation, whereas extension (r = 0.42; P < 0.05) showed a lesser correlation. Correlation of the measurements taken radiographically and by inclinometer demonstrated an almost linear correlation for measurements of the total lumbar range of motion (r = 0.97; P < 0.001) and flexion (r = 0.98; P < 0.001), whereas extension (r = 0.75; P < 0.001) did not correlate as well. The noninvasive inclinometer technique proved to be highly reliable and valid, but the measurement technique for extension needs further refinement.
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.
Article
Cross-sectional data were collected in a postal questionnaire within the framework of a 5-year randomized, controlled, prospective, population-based study. To investigate to what extent associations differ or concur when correlates of low back pain are rested against various subdefinitions of low back pain. Numerous factors have been suspected to cause low back pain, but findings have not been constantly reproduced in epidemiologic studies. Data were collected on 748 people reporting nonspecific low back pain some time during the year preceding the survey. Six correlates of low back pain (age, sex, marital status, attitude to a healthy life-style, self-reported physical activity at work, and smoking) were cross-tabulated against nonspecific low back pain and against four subgroups of low back pain. There was only one statistically significant strong association between the potential risk indicators and the nonspecific definition of low back pain, but several emerged when the low back pain group was split into subgroups. Different subgroups of low back pain did, indeed, relate differently to the various correlates. It is necessary to define some clinically relevant subgroups of low back pain to accelerate the search for causal mechanisms.
Article
Rapid shoulder movement is preceded by contraction of the abdominal muscles to prepare the body for the expected disturbance to postural equilibrium and spinal stability provoked by the reactive forces resulting from the movement. The magnitude of the reactive forces is proportional to the inertia of the limb. The aim of the study was to investigate if changes in the reaction time latency of the abdominal muscles was associated with variation in the magnitude of the reactive forces resulting from variation in limb speed. Fifteen participants performed shoulder flexion at three different speeds (fast, natural and slow). The onset of EMG of the abdominal muscles, erector spinae and anterior deltoid (AD) was recorded using a combination of fine-wire and surface electrodes. Mean and peak velocity was recorded for each limb movement speed for five participants. The onset of transversus abdominis (TrA) EMG preceded the onset of AD in only the fast movement condition. No significant difference in reaction time latency was recorded between the fast and natural speed conditions for all muscles. The reaction time of each of the abdominal muscles relative to AD was significantly delayed with the slow movement compared to the other two speeds. The results indicate that the reaction time latency of the trunk muscles is influenced by limb inertia only with limb movement below a threshold velocity.
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There have been no previous studies that quantitatively assessed the load on the spine during extensor exercises. The purpose of our study was to investigate the loading of the lumbar spine and trunk muscle activity levels while subjects performed typical trunk extensor exercises. Thirteen male volunteers (mean age = 21.0 years, SD = 1.0, range = 19-23; mean height = 176.0 cm, SD = 6.2, range = 165-188; mean mass = 77.0 kg, SD = 7.0, range = 63-89) participated. The subjects performed four different back exercises. Electromyographic (EMG) activity was recorded from 14 trunk muscles. The postures that corresponded to the maximum external moment were identified and quantified using rigid body modeling combined with an EMG-driven model to determine joint loading at the L4-5 joint. The exercises were then evaluated based on the lumbar spine loading and peak muscle activity levels. A reference task of lifting 10 kg from midthigh was included for comparison. The exercises involving active trunk extension produced the highest joint forces and muscle activity levels. Exercises involving leg extension with the spine held isometrically demonstrated asymmetrical activity of the trunk muscles, thereby reducing loads on the spine. The back extensor exercises examined provided a wide range of joint loading and muscle activity levels. Single-leg extension tasks appear to constitute a low-risk exercise for initial extensor strengthening, given the low spine load and mild extensor muscle challenge. When combined with contralateral arm extensions, the challenge and demand of the exercise were increased. The compressive loading and extensor muscle activity levels were highest for the trunk extension exercises.
Article
Reduction in lumbar muscular activity at full body flexion, known as flexion relaxation, has been studied in relation to overall trunk, lumbar spine, and hip flexion, but has not been evaluated in conjunction with motion on the segmental level. In this study, intervertebral motion in a lumbar motion segment, trunk flexion, and the electromyographic activity in the lumbar erector spinae muscles were simultaneously measured during dynamic flexion-extension in seven patients with chronic low back pain with symptoms suggesting segmental instability and in six asymptomatic controls. A linkage system, which attached directly to the spinous processes of a lumbar motion segment, was used to continuously measure the sagittal plane intervertebral motion, while a potentiometric goniometer measured trunk flexion; myoelectric activity was measured using surface electrodes. It was found that intervertebral motions, as well as trunk mobility, were significantly less in the patients, both in terms of range and pattern of motion. Flexion relaxation was demonstrated in the controls by a 78% decrease in myoelectric activity at full flexion, whereas in the patients, only a 13% reduction was found, with most of the patients experiencing no reduction at all. Flexion relaxation occurred only in subjects in whom intervertebral rotation had reached a stage of completion considerably before full trunk flexion was achieved. These findings suggest that persistent muscle activation, which restricts intervertebral motion, is a means by which the neuromuscular system provides stability to help protect diseased passive spinal structures from movements that may cause pain.