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Differences in Sitting Postures are Associated With Nonspecific Chronic Low Back Pain Disorders When Patients Are Subclassified
Abstract
A comparative study.
To investigate sitting postures of asymptomatic individuals and nonspecific chronic low back pain (NS-CLBP) patients (pooled and subclassified) and evaluate the importance of subclassification.
Currently, little evidence exists to support the hypothesis that CLBP patients sit differently from pain-free controls. Although classifying NS-CLBP patients into homogeneous subgroups has been previously emphasized, no attempts have been made to consider such groupings when examining seated posture.
Three angles (sacral tilt, lower lumbar, and upper lumbar) were measured during "usual" and "slumped" sitting in 33 NS-CLBP patients and 34 asymptomatic subjects using an electromagnetic measurement device. Before testing, NS-CLBP patients were subclassified by two blinded clinicians. Twenty patients were classified with a flexion motor control impairment and 13 with an active extension motor control impairment.
No differences were found between control and NS-CLBP (pooled) patients during usual sitting. In contrast, analyses based on subclassification revealed that patients classified with an active extension pattern sat more lordotic at the symptomatic lower lumbar spine, whereas patients with a flexion pattern sat more kyphotic, when compared with healthy controls (F = 19.7; df1 = 2, df2 = 63, P < 0.001). Further, NS-CLBP patients had less ability to change their posture when asked to slump from usual sitting (t = 4.2, df = 65; P < 0.001).
Differences in usual sitting posture were only revealed when NS-CLBP patients were subclassified. This highlights the importance of subclassifying NS-CLBP patients.
... Objective comparisons of spinal and pelvic kinematics have been performed in laboratory settings and have identified distinct variations in clinical subgroups of NSLBP in the upper and lower lumbar spine and the pelvis during various functional movement tasks [20][21][22][23][24]. The cost and expertise required for laboratory movement analysis, however, prohibit this level of assessment in clinical settings at scale. ...
... These results align with observations from Dankaerts et al. [37], who assessed similar subgroups and found that during flexion, participants with EP-NSLBP moved with an extended spine, while participants with FP-NSLBP achieved comparable lower lumbar flexion to the no-LBP counterparts. In contrast to our findings, a previous study by Dankaerts et al. [22] reported that, during sitting, individuals with FP-NSLBP had a more flexed upper lumbar spine curvature compared to asymptomatic individuals. Methodological discrepancies may have contributed to the contrasting findings. ...
... Although statistically different, a closer inspection revealed similar age and BMI category distributions across the subgroups, suggesting a limited impact on the overall results. However, the subgroup difference in sex distribution must be acknowledged as a potential confounder, particularly considering the distinct impairments prevalence among the different sexes shown in previous MCI cohort comparisons [20,22,23]. Future NSLBP MCI classification research should consider the influence of sex distribution on lumbo-pelvic kinematics across subgroups. ...
Inertial measurement units (IMUs) offer a portable and quantitative solution for clinical movement analysis. However, their application in non-specific low back pain (NSLBP) remains underexplored. This study compared the spine and pelvis kinematics obtained from IMUs between individuals with and without NSLBP and across clinical subgroups of NSLBP. A total of 81 participants with NSLBP with flexion (FP; n = 38) and extension (EP; n = 43) motor control impairment and 26 controls (No-NSLBP) completed 10 repetitions of spine movements (flexion, extension, lateral flexion). IMUs were placed on the sacrum, fourth and second lumbar vertebrae, and seventh cervical vertebra to measure inclination at the pelvis, lower (LLx) and upper (ULx) lumbar spine, and lower cervical spine (LCx), respectively. At each location, the range of movement (ROM) was quantified as the range of IMU orientation in the primary plane of movement. The ROM was compared between NSLBP and No-NSLBP using unpaired t-tests and across FP-NSLBP, EP-NSLBP, and No-NSLBP subgroups using one-way ANOVA. Individuals with NSLBP exhibited a smaller ROM at the ULx (p = 0.005), LLx (p = 0.003) and LCx (p = 0.01) during forward flexion, smaller ROM at the LLx during extension (p = 0.03), and a smaller ROM at the pelvis during lateral flexion (p = 0.003). Those in the EP-NSLBP group had smaller ROM than those in the No-NSLBP group at LLx during forward flexion (Bonferroni-corrected p = 0.005), extension (p = 0.013), and lateral flexion (p = 0.038), and a smaller ROM at the pelvis during lateral flexion (p = 0.005). Those in the FP-NSLBP subgroup had smaller ROM than those in the No-NSLBP group at the ULx during forward flexion (p = 0.024). IMUs detected variations in kinematics at the trunk, lumbar spine, and pelvis among individuals with and without NSLBP and across clinical NSLBP subgroups during flexion, extension, and lateral flexion. These findings consistently point to reduced ROM in NSLBP. The identified subgroup differences highlight the potential of IMU for assessing spinal and pelvic kinematics in these clinically verified subgroups of NSLBP.
... A sitting posture with a flexed spine results in more lost fluid from the nucleus pulpous than an erect posture, which may contribute to insufficient nutrition of the lumbar discs (7). Hyper-lordosis during sitting induced consistently increased activation of the back extensor muscles and excessive compressive pressure in the facet joints of the spine (8,9). Consequently, to adopt a lumbar sitting posture that reduces passive tissue strain, slight lumbar lordosis and a relaxed thorax are important to prevent and resolve LBP during seated work (10). ...
... A prolonged flexed sitting posture contributes to increasing the intervertebral disc pressure (5, 23) and cervical lordosis and pelvic tilt (24) while sitting. Less activity of the back muscles (i.e., the lumbar multifidus, iliocostalis lumborum, and thoracic erector spinae) is required with a flexed lumbar posture (8,19,25); however, it can induce more stress on the articular and ligamentous structures. Although we did not assess muscle activity in the lumbar region during sitting, a pelvic support chair may induce passive anterior pelvic tilt, which would contribute to an increased lumbar lordotic angle, thus requiring less effort to maintain a lumbar posture compared to active erect sitting. ...
... This study demonstrated that the LLA was significantly decreased in patients with LBP compared with that in controls. Previous studies have found an association between sitting in an awkward posture (e.g., trunk flexed or a bent posture) and presence or severity of LBP, although whether there is a strong association between sitting itself and LBP remains unknown (2,8,26,27). Decreased lumbar lordosis has been considered as an important factor in the development of LBP during prolonged sitting with flattening of the lumbar spine (2,8,26,27). ...
Background: A slouched lumbar posture during sitting is risk factor for the low back pain (LBP). Various chairs have been used to maintain sagittal lumbar lordosis and sacral alignment during sitting. We aimed to demonstrate the effect of a pelvic-support chair on the lumbar lordosis and sacral tilt in patients with LBP.
Methods: We recruited 29 patients with non-specific LBP and 11 healthy subjects in South Korea from Apr 2017 to Mar 2018. The sagittal lumbosacral alignment was examined radiographically in three sitting postures: usual, erect, and sitting in a pelvic-support chair. Five angles [the lumbar lordosis, upper lumbar (ULA), lower lumbar (LLA), lumbosacral (LSA), and sacral slope (SS) angles] were compared between the subjects with LBP and healthy subjects in the three sitting conditions.
Results: There were significant differences in the lumbar lordosis, ULA, LLA, LSA, and SS according to sitting condition (P
... reaching [10][11][12] . The variation in muscle recruitment patterns and spinal kinematics in different subtype of LBP had also been reviewed in earlier studies. ...
... 1. Superficial and deep muscles (RA-ES and IO-LM) 2. Flexors and extensors (RA-IO and ES-LM) Exclusion Criteria (applicable to all three groups) 18 Exclusion Criteria of LBP groups 18,19 • Acute or unhealed fracture • Bones incapable of bearing body weight due to pathology • Implantation of pacemakers and/or defibrillators • Any red flags including neoplastic disease of the spine and certain bone diseases including infections 19 Inclusion Criteria of LBP groups 10,11 • No experience of LBP within the last 12 months • No experience of an episode of LBP lasting more than two weeks within the last two years ...
This cross-sectional study aimed to compare the change in spinal posture, mechanical stiffness, and motor control of the thoracolumbar spine in individuals who were asymptomatic and those with chronic nonspecific low back pain (LBP) of flexion pattern (FP) or active extension pattern (AEP) during pushing and pulling tasks performed in standing. The real-time thoracolumbar posture, mechanical stiffness, electromyographic amplitude and synergy between specified trunk muscle pairs (Internal Oblique and Multifidus, Rectus Abdominis and Erector Spinae, Internal Oblique and Rectus Abdominis, Multifidus and Erector Spinae) were analysed during quiet standing, standing pushing and pulling tasks against a load standardized at 15% of the individual body weight in a total of 39 individuals (asymptomatic, n = 14; FP, n = 11; AEP, n = 14). Pulling task resulted in greater lumbar posterior translation (p = 0.009) and Rectus Abdominis activity (p = 0.006), but smaller lumbar lordosis (p < 0.001) when compared to pushing task. Pulling task also resulted smaller lumbar lordosis (p < 0.001) and thoracic kyphosis (p = 0.003) comparing to upright standing. AEP group showed a significantly greater amplitude of their Internal Oblique activity when compared to those who were asymptomatic across all tasks (p = 0.001). Findings suggested that pulling manoeuvre in standing produced greater shear at the lumbar spine than that of pushing manoeuvre. Individuals with low back pain executed the low-load push/pull tasks with the motor strategy largely comparable to asymptomatic group. Future studies investigating the cumulative effect of repetitive push/pull loadings on the movement and motor control of the spine are warranted to better understand the long-term impacts on spinal health.
... Conventionally, the LLA is derived from radiographic images using the Cobb angle, formed between the lines at the inferior endplate of T12 and the superior endplate of S1 (Figure 1d) [50]. When measuring with inertial sensors, the placement can vary slightly among studies; we adhered to the protocols of previously related studies [42,51]. The relative angle between T12 and S2 was calculated using a simple subtraction method, and the Y-axis (mediolateral axis) data were used to evaluate the kyphosis-lordosis of lumbar movement between the T12 and S2 IMU sensors. ...
... Conventionally, the LLA is derived from radiographic images using the Cobb angle, formed between the lines at the inferior endplate of T12 and the superior endplate of S1 (Figure 1d) [50]. When measuring with inertial sensors, the placement can vary slightly among studies; we adhered to the protocols of previously related studies [42,51]. ...
Background/Objectives: Lumbar lordotic curvature (LLC), closely associated with low back pain (LBP) when decreased, is infrequently assessed in clinical settings due to the spatiotemporal limitations of radiographic methods. To overcome these constraints, this study used an inertial measurement system to compare the magnitude and maintenance of LLC across various sitting conditions, categorized into three aspects: verbal instructions, chair type, and desk task types. Methods: Twenty-nine healthy participants were instructed to sit for 3 min with two wireless sensors placed on the 12th thoracic vertebra and the 2nd sacral vertebra. The lumbar lordotic angle (LLA) was measured using relative angles for the mediolateral axis and comparisons were made within each sitting category. Results: The maintenance of LLA (LLAdev) was significantly smaller when participants were instructed to sit upright (−3.7 ± 3.9°) compared to that of their habitual sitting posture (−1.2 ± 2.4°) (p = 0.001), while the magnitude of LLA (LLAavg) was significantly larger with an upright sitting posture (p = 0.001). LLAdev was significantly larger when using an office chair (−0.4 ± 1.1°) than when using a stool (−3.2 ± 7.1°) (p = 0.033), and LLAavg was also significantly larger with the office chair (p < 0.001). Among the desk tasks, LLAavg was largest during keyboard tasks (p < 0.001), followed by mouse and writing tasks; LLAdev showed a similar trend without statistical significance (keyboard, −1.2 ± 3.0°; mouse, −1.8 ± 2.2°; writing, −2.9 ± 3.1°) (p = 0.067). Conclusions: Our findings suggest that strategies including the use of an office chair and preference for computer work may help preserve LLC, whereas in the case of cueing, repetition may be necessary.
... Due to the heterogenous nature of LBP, studies suggest that deficits that were hidden can be revealed via subgrouping (Dankaerts et al. 2006;Astfalck et al. 2010) and more effective interventions matching to these subgroups can be applied (Brennan et al. 2006). High rates of chronicity and recurrence of LBP suggest that preventive and treatment strategies may be inadequate (Andersson 1999), pointing out the need for better understanding of LBP. ...
... A systematic review with meta-analysis showed that individuals with LBP show impairments in lumbar proprioception compared with controls when measured in sitting positions via active JRET (Tong et al. 2017). Given the vast range of presentations of LBP encompassing various levels of mechanical impairment and pain intensity, studies suggest that impairments may only be revealed upon the application of subgrouping (Dankaerts et al. 2006;Astfalck et al. 2010;Soliman et al. 2017). In this study, we measured lumbar proprioception in sitting position via active JRET and showed that proprioception did not differ between acute, subacute and chronic stages of LBP. ...
Purpose/Aim
Postural control, proprioception and lower extremity muscle strength are affected in individuals with low back pain (LBP). However, it is yet unknown whether these variables differentiate between acute, subacute and chronic stages of LBP. The aim was to investigate if there were any differences in postural control, proprioception, lower extremity muscle strength, pain intensity and disability between individuals in the different stages of LBP.
Materials and Methods
In this cross-sectional study, 124 individuals with LBP were grouped as acute LBP (ALBP) (n = 38), subacute LBP (SLBP) (n = 30) and chronic LBP (CLBP) (n = 56) groups. Postural control was assessed via computerised technology. Lumbar proprioception, lower extremity muscle strength, pain intensity and disability were assessed using Joint Repositioning Error Test, hand-held dynamometer, Numeric Rating Scale and Oswestry Disability Index (ODI), respectively. Kruskal–Wallis Tests, ANCOVA and post hoc Mann–Whitney U-Test with Bonferroni correction were performed.
Results
While there were no significant differences in terms of postural control, proprioception and pain intensity (p > 0.05), significant differences were found in terms of lower extremity muscle strength and ODI scores between groups when adjusted for age (p < 0.05). Individuals with CLBP demonstrated poorer lower extremity muscle strength than those with ALBP and SLBP, and higher disability than those with ALBP (p < 0.017).
Conclusions
Although postural control, proprioception and pain intensity were similar between individuals with acute, subacute and chronic LBP, muscle strength and disability seem to worsen stepwise as the pain becomes chronic. Muscle strength and disability should be taken into account while evaluating and/or managing individuals with acute and subacute stages of LBP.
... posture is essential. Previous studies indicate that proper posture helps maintain body alignment and minimize muscle tension, thereby reducing the negative impacts associated with prolonged sitting [4][5][6]. ...
Background
Sedentary lifestyles can lead to musculoskeletal disorders, but proper sitting posture, particularly maintaining a slight anterior pelvic tilt, helps prevent issues like lower back pain and spinal misalignment. Samsung Electronics wearable robot ‘Bot Fit’ improves posture by enhancing core muscle tension, reducing trapezius muscle tension, and improving spinal alignment, which can alleviate pain and improve overall musculoskeletal health.
Objective
This study was conducted to evaluate the effectiveness of Samsung’s wearable robot, ‘Bot Fit’, in promoting proper sitting posture.
Methods
This study involved 37 participants, including healthy adults, elderly individuals. Participants were evaluated under two conditions, with and without the Bot Fit device, while seated on a Bobath table. Muscle tension, spinal angles, sitting height, and gluteal pressure distribution were measured under both conditions, and statistical analysis was conducted using paired t-tests with a significance level of p = 0.05.
Results
Participants showed a significant increase in sitting height and rectus abdominis muscle tone, while upper trapezius muscle tone significantly decreased (p < 0.05). Additionally, hip pressure increased across all regions, and pressure differences between the left and right hips decreased significantly (p < 0.01).
Conclusion
Wearing the Bot Fit with its posture correction function improved muscle tone and sitting posture in adults and the elderly, potentially helping to prevent secondary musculoskeletal disorders from poor posture. Future research should explore the optimal torque settings of the Bot Fit based on individual factors like weight and gender.
... Good postural alignment is positively associated with safe 1 , mechanically effective and meaningful engagement in occupations 2 . Health care professionals assess posture in clinical settings by using a variety of methods 3,4,5 which range from simple visual observation in clinical practice 6 , to more complex quantitative assessments of postural alignment 7,8,9 . Many of these systems however proved to be timeconsuming, complex and are difficult to use outside the laboratory environment, such as in the context of community and hospital settings. ...
Introduction: Good postural alignment is positively associated with safe, mechanically effective and meaningful engagement in occupations. Health care professionals assess posture in clinical settings by using a variety of methods ranging from simple visual observation, to more complex quantitative assessments of postural alignment, which are costly and mostly done in laboratory environments. The need exists for a cost effective and user-friendly method for the assessment of posture in clinical settings and research studies. Objectives: The aim of this study was to develop a Photographic Method of Postural Assessment (P-MPA) that quantitatively measures postural alignment, and to determine the validity and reliability of the P-MPA. Methods: A graph, representing graphic postural alignment, was used consisting of a vertical line that represents the five levels of anatomical landmarks, with a horizontal line crossing the vertical line at each of the five levels. A total of 20 points were randomly plotted on the five horizontal lines. The graph was photographed using a smartphone, and A4 sized photographs were printed. Fifty participants measured and noted the distance deviations between the points on the horizontal lines and the vertical line. The actual deviation from the vertical line was calculated using a ratio of measured to real distance. Results: The distance deviation between measured and actual distances was statistically significant for certain anatomical landmarks as indicated by 95% Confidence Intervals and Limits of Agreement. With respect to the anatomical landmarks and respective points, no clinically significant differences were observed, as a difference of less than 10mm was found. Recommendations: It is recommended that the P-MPA be used, as a user-friendly and cost-effective method, for measuring postural alignment in clinical settings, and, that it be further developed and investigated as measurement tool for both single and multiple-joint research studies during activity performance. Keywords: Posture assessment, validity, reliability
... Ce type de posture peut être lié à la croyance qu'il est important de se tenir droit pour éviter le mal de dos, ce qui n'est évidemment pas juste. En effet, un maintien du dos en position neutre ou en extension augmente l'activité musculaire, ce qui peut provoquer des douleurs [79] . Une modification de cette posture vers une position de relâchement, si elle n'est pas associée à une augmentation des douleurs, pourrait être une piste de traitement. ...
La lombalgie est l’une des principales causes d’invalidité dans le monde, entraînant une diminution de la qualité de vie et un fardeau économique considérables. Environ 90 % des personnes souffrant de lombalgie présentent une lombalgie commune ou non spécifique. Pour les autres cas, une combinaison d’informations à l’évaluation de la personne permet d’établir un niveau de suspicion vers une lombalgie spécifique, qui nécessite généralement une prise en charge plus ciblée, voire urgente. Une fois les pathologies sérieuses écartées, l’évaluation doit s’inscrire dans une approche contemporaine et multidimensionnelle, intégrant des facteurs biologiques, psychologiques et sociaux. Elle doit être centrée sur les besoins et les limitations fonctionnelles de la personne, incluant l’identification du mécanisme de douleur dominant et des facteurs de risque de chronicisation. Une attention particulière est accordée à l’exploration des croyances de la personne sur ses douleurs lors de l’anamnèse, celles-ci ayant une influence importante sur les résultats du traitement. Des questionnaires tels que le Start Back Tool ou l’Orebro sont utiles pour identifier les facteurs de risque de chronicisation. L’examen physique doit prioritairement évaluer les comportements fonctionnels ainsi que la reproduction et la modification des symptômes. Les questionnaires Patient-Reported Outcome Measures (PROM) complètent les informations collectées lors de l’anamnèse et de l’examen physique, permettant d’évaluer l’évolution de la personne.
Trois dimensions de PROM sont particulièrement recommandées : le handicap fonctionnel, l’intensité de la douleur et la qualité de vie. Enfin, dans une approche centrée sur la personne, les résultats de l’évaluation et les hypothèses sont partagés avec celle-ci, et la prise en charge est planifiée de manière collaborative.
... Previous studies, comparing sitting between individuals with LBP and those without, have focused specifically on a single snapshot in time, usually a laboratory assessment [32,33]. Findings describing individuals with LBP and demonstrating differences from those without LBP [9] have the potential to make erroneous conclusions. ...
Low back pain affects 619 million people worldwide and is commonly provoked by sitting. Current assessment methods constrain task variability, removing real-world, task-switching behaviors. This study utilized accelerometers to provide an original validated method of in vivo real-world assessment of lumbar sitting behavior throughout a full day. A three-stage study design was used, which involved (1) blinded verification of our sitting detection algorithm, (2) full-day data collection from participants with low back discomfort, quantifying lumbar angles, and end-user acceptability explored, (3) case study application to two clinical low back pain (LBP) patients, incorporating measurement of provocative sitting. Focus group discussions demonstrated that data collection methods were acceptable. Sitting ‘windows’ were created and analyzed using novel histograms, amplitude probability distribution functions, and variability, demonstrating that sitting behavior was unique and varied across individuals. One LBP patient demonstrated two frequent lumbar postures (<15% flexion and ~75% flexion), with pain provocation at 62% lumbar flexion. The second patient demonstrated a single dominant posture (~90% flexion), with pain provoked at 86% lumbar flexion. Our in vivo approach offers an acceptable method to gain new insights into provocative sitting behavior in individuals with LBP, allowing individualized unconstrained data for full-day postures and pain provocation behaviors to be quantified, which are otherwise unattainable.
... Besides ROM, other segmental kinematic parameters have been used to classify patients with NSCLBP into different subgroups, such as lumbar spine angles (lower and upper lumbar) in standing posture [23][24][25] or sitting trunk flexion 26 . To our knowledge, the relationships between FRP and these other multi-segmental kinematic parameters of the spine have not yet been studied in NSCLBP patients. ...
The flexion relaxation phenomenon (FRP) is characterized by the reduction of paraspinal muscle activity at maximum trunk flexion. FRP is reported to be altered (persistence of spinal muscle activity) in more than half of nonspecific chronic low back pain (NSCLBP) patients. Little is known about how the multi-segmental spine affects FRP. The aim of this observational study was to investigate the relationship between FRP and kinematic parameters of the multi-segmental spine in NSCLBP patients. Forty NSCLBP patients and thirty-five asymptomatic participants performed a standing maximal trunk flexion task. Surface electromyography was recorded along the erector spinae longissimus. The kinematics of the spine were assessed using a 3D motion analysis system. The investigated spinal segments were upper thoracic, lower thoracic, thoracolumbar, upper lumbar, lower lumbar, and lumbopelvic. Upper lumbar ROM, anterior sagittal inclination of the upper lumbar relative to the lower lumbar in the upright position, and ROM of the upper lumbar relative to the lower lumbar during full trunk flexion were significantly correlated with the flexion relaxation ratio (Rho 0.42 to 0.58, p < 0.006). The relative position and movement of the upper lumbar segment seem to play an important role in the presence or absence of FRP in NSCLBP patients.
... Postural correction is an important element of physical therapy management of patients with back dysfunction. Although the relationship between posture and back pain is largely undefined, it has been proposed that end result of sitting and standing postures, were shown to be associated with changing in muscle activation patterns ) 7,8,9,10( that put excessive stresses on the passive spinal structures including ligaments, disks and facet joint, capsules and could potentially pose a risk to the progression of back complain )11( . The dependance on clinical examination alone has many limitations, as subjective participation of the observer and the lack of many important qualitative measurement data in each evaluation. ...
... This behavior is typical for people with LBP. They show more frequent static, end-range postures with less small and more large infrequent movements [83,84]. The chair could be useful for people with static sitting behavior and/or LBP. ...
Introduction
Inactivity and long periods of sitting are common in our society, even though they pose a health risk. Dynamic sitting is recommended to reduce this risk. The purpose of this study was to investigate the effect of continuous passive motion (CPM) conducted by a novel motorized office chair on lumbar lordosis and trunk muscle activation, oxygen uptake and attentional control.
Study design
Randomized, single-session, crossover with two periods/conditions.
Methods
Twenty office workers (50% women) sat for one hour on the motorized chair, one half with CPM, the other not. The starting condition (CPM/no CPM) was switched in half of the sample. The participants were equipped with a spirometric cart, surface EMG, the Epionics SPINE system and performed a computer-based test for attentional control (AX-CPT). Outcomes were lumbar sagittal movements and posture, number of trunk muscle activations, attentional control and energy expenditure.
Results
The CPM of the chair causes frequent low-amplitude changes in lumbar lordosis angle (moved: 498 ± 133 vs. static: 45 ± 38) and a higher number of muscle activations. A periodic movement pattern of the lumbar spine according to the movement of the chair was observed in every participant, although, sitting behavior varied highly between individuals. Attentional control was not altered in the moved condition (p = .495; d = .16). Further, oxygen uptake did not increase higher than 1.5 MET.
Conclusion
The effects of the motorized chair can be particularly useful for people with static sitting behavior. Further studies should investigate, whether CPM provides the assumed beneficial effects of dynamic sitting on the spine.
... Previous studies demonstrating that PwF are more physically inactive than the general population concluded that researchers and clinicians should in particular consider pain as a core outcome measure in all non-pharmacological fibromyalgia trials and clinical recommendations [34][35][36]. From a clinical perspective, PwF should, for example, be made aware that excessive sitting might contribute to pain, disability and consequently the impact of their disease through tightening of lower extremity musculature, decreased blood circulation, physical deconditioning, and poor posture [37]. Furthermore, PwF should be made aware that those experiencing chronic pain may have the tendency to avoid movement for fear of pain, which might result in a lack of motivation to engage in physical activity and create a vicious circle where pain represents both a cause and a consequence of physical inactivity and indirectly also sedentary behaviour [38]. ...
Purpose:
Sedentary behaviour is associated with pain, fatigue, and a more severe impact of the disease in fibromyalgia, independently of physical activity levels. Despite this knowledge, little attention has been attributed to estimate sedentary behaviour in this population. The aims of this meta-analysis were to: (a) establish the pooled mean time spent sedentary, (b) investigate moderators of sedentary levels, and (c) explore differences with age- and gender-matched general population controls in people with fibromyalgia (PwF).
Methods:
Two independent authors searched major databases until 1 December 2022. A random effects meta-analysis was performed. The methodological quality of included studies was assessed with the Quality Assessment Tool for Observational Cohort and Cross-sectional Studies.
Results:
Across 7 cross-sectional studies of fair methodological quality, there were 1500 patients with fibromyalgia (age range = 43-53 years). PwF spent 545.6 min/day (95% CI = 523.7-567.5, p < 0.001, N = 3) engaging in sedentary behaviour. Self-reported questionnaires overestimate sedentary levels with 314.3 min/day (95% CI = 302.0-326.6, p = 0.001, N = 2). PwF spent 36.14 min/day (95% CI = 16.3-55.9, p < 0.001) more in sedentary behaviour than general population controls.
Conclusions:
PwF are more sedentary than the general population. The limited available data should however be considered with caution due to substantial heterogeneity.IMPLICATIONS FOR REHABILITATIONRehabilitation for fibromyalgia should emphasize reducing sedentary behaviour.Health professionals should measure sedentary levels objectively in fibromyalgia since self-report underestimates the actual levels severely.More research on risk factors for sedentary behaviour in fibromyalgia is needed before detailed recommendations can be formulated.
... [43]. Les preuves scientifiques sur la présence d'une altération du contrôle moteur dans la lombalgie chronique ne cessent de croître [44][45][46]. ...
... and consequently the impact of their disease through tightening of lower extremity musculature, decreased blood circulation, physical deconditioning, and poor posture. 38 Furthermore, PwF should be made aware that those experiencing chronic pain may have the tendency to avoid movement for fear of pain or reinjury which might results in a lack of motivation to engage in PA and creating a vicious circle where pain represents both a cause and a consequence of SB. 39 These findings align with the fear-avoidance model of chronic pain, 40 postulating that pain-related fear increases when bodily sensations, including sensations when being physically active, are catastrophized (eg, sensations are perceived as a significant threat to bodily integrity). 40 An increase in pain-related fear then provokes the initiation of several safety behaviors, including avoidance of PA and increased SB. 40 Being physically inactive and sedentary may then lead to physical and mental deconditioning. ...
Introduction
Understanding the correlates of sedentary behavior (SB) is important in the development of interventions which reduce and interrupt SB in people with fibromyalgia (PwF). This systematic review aimed to investigate the correlates of SB in PwF using the socio‐ecological model.
Methods
Three databases (Embase, CINAHL and PubMed) were search from inception until July 21, 2022 using “sedentary” or different types of SB and “fibromyalgia” or “fibrositis” as keywords. The data collected was then analyzed using summary coding.
Results
Out of 23 SB correlates retrieved from 7 reports (n = 1698), no correlates were consistently reported (ie, reported in 4 or more studies). Higher pain intensity was the most commonly reported barrier for reducing/interrupting SB (reported in 3 reports). Other reported barriers to reducing/interrupting SB were experiencing physical and mental fatigue, a more severe disease impact, and a lack of motivation to be physically active (all reported in 1 study). A better experienced social and physical functioning and more vitality were facilitators for reducing/interrupting SB (all reported in 1 study). To date, in PwF no correlates of SB at the interpersonal, environmental and policy levels have been explored.
Conclusion
Research on correlates of SB in PwF is still in its infancy. The current preliminary evidence suggests that clinicians should consider physical and mental barriers when aiming to reduce or interrupt SB in PwF. Further research on modifiable correlates at all levels of the socio‐ecological model is required to inform future trials aiming to modify SB in this vulnerable population.
... Thus, the observation process of the therapist in daily work was imitated. The results showed that most of the rehabilitation practitioners consid- However, some studies have pointed out that sitting positions 4 and 5 of lumbar lordosis activate more trunk muscles than the flat-back posture 2 [17,22,23], which may cause neck pain [24] and low back pain [25]. The long-term maintenance of the lumbar lordosis sitting posture is also questioned, as this state may exceed the bearing capacity of the paraspinal muscles [22], resulting in greater fatigue, pain, and discomfort in the neck and waist [26]. ...
The concepts of “optimal posture (OP)” and “harmful posture (HP)” are commonly used, and specific spinal postures can contribute to back pain. However, quantitative descriptions of optimal and harmful standing (StP) and sitting (SP) postures are currently lacking, particularly for different body mass indices (BMIs). Therefore, this study aimed to identify and quantify the OPs and HPs of StP and SP at different BMIs and investigate the attitudes and beliefs of rehabilitation practitioners toward OPs and HPs. Overall, 552 rehabilitation practitioners were recruited to participate in a questionnaire survey to select the optimal position from seven sitting and five standing postures for each BMI healthy volunteer. The segmental relationships of each posture were qualified using the Vicon software. For normal BMI, the physiotherapists chose two SPs (48.19% and 49.64%) and one StP (80.42%) as the OP. One sitting SP (83.7%) and two standing StPs (43.48% and 48.19%) were selected as optimal for obese BMI. All the most commonly selected OPs had an upright lordotic posture, while the postures with slouched spinal curves or forward head postures were almost all selected as HP. Additionally, 96.74% of participants considered education about optimal SP and StP to be “quite” or “very” important. The OP of the StP and SP postures was mostly based on the vertical alignment of gravity lines and sagittal balance. For obese people, the rehabilitation practitioners’ observations may be erroneous, and further physical examination is necessary. Rehabilitation practitioners generally believe that postural education is essential in clinical practice.
... The other demonstration aimed to monitor the large strains on the lower back, which is a critical signal for metabolic syndrome and spine issues. 57,58 The sensor was integrated onto an athletic tape by fixing the two ends of the sensor on the tape using a PDMS precursor (Figure 5c, inset). Two sensor/tape setups were attached on the lower back side by side in parallel with the spine. ...
Soft and stretchable strain sensors have been attracting significant attention. However, the trade-off between the sensitivity (gauge factor) and the sensing range has been a major challenge. In this work, we report a soft stretchable resistive strain sensor with an unusual combination of high sensitivity, large sensing range, and high robustness. The sensor is made of a silver nanowire network embedded below the surface of an elastomeric matrix (e.g., poly(dimethylsiloxane)). Periodic mechanical cuts are applied to the top surface of the sensor, changing the current flow from uniformly across the sensor to along the conducting path defined by the open cracks. Both experiment and finite element analysis are conducted to study the effect of the slit depth, slit length, and pitch between the slits. The stretchable strain sensor can be integrated into wearable systems for monitoring physiological functions and body motions associated with different levels of strain, such as blood pressure and lower back health. Finally, a soft three-dimensional (3D) touch sensor that tracks both normal and shear stresses is developed for human-machine interfaces and tactile sensing for robotics.
... This general increase in cervical muscle activity can be considered to reflect a modulation of the neck kinematic impairment, which occurred as a defensive response to neck pain associated with motion, to carry out the motion while maintaining its stability and inhibiting neck motion. The modulation in motor control is believed to continually give rise to abnormal loads on the tissues to cause mechanically provoked pain [45][46][47]. Since there is little contribution of ligaments to neck stability, the cervical muscles are thought to play an important role [6], especially the synergy of the superficial and deep cervical muscle activity, for the stability of the neck [48]. ...
Background and Objectives: We identified typical surface electromyogram (sEMG) activities of the cervical extensors and flexors during motions in the three anatomical planes in healthy adults. The aim of this study was to explore characteristics of sEMG activities of these cervical muscles in nonspecific neck pain (NSNP) patients based on healthy adults. Materials and Methods: Participants were 24 NSNP patients (NSNP group, mean ± SD of age, 47.5 ± 15.5) and 24 healthy adults (control group, 20.5 ± 1.4). For each participant, sEMG of the cervical extensors and flexors was recorded during neck flexion, extension, bilateral lateral flexion, bilateral rotation, and at the neutral position in Phase I (the neck from the neutral position to the maximum range of motion), Phase II (at the maximum range of motion), and Phase III (from the maximum range of motion to the neutral position), yielding a total of 42 phases. A percentage of maximum voluntary contraction to normalize muscle activity in each phase was calculated to obtain the ratio of muscle activities in the extensors and flexors in each of 36 phases of the motions to the neutral position and ratio of the flexors to extensors in activity for 21 phases. Results: In 28 of 36 phases of the motions, the ratios of muscle activities in the extensors and flexors to the neutral position in the NSNP group were significantly larger than the control group (p < 0.05). In 6 of 21 phases, the ratios of the flexors to extensors in activity in the NSNP group were significantly larger than in the control group (p < 0.05). Conclusions: In NSNP patients, the activity of the cervical extensors and flexors associated with neck motion increased with an imbalance in activity between these muscles compared to their activity in healthy adults. The results of this study will be useful in understanding the pathogenesis of NSNP and in constructing an objective evaluation of the treatment efficacy on NSNP patients.
... When learning to use a new assistive technology, such as an exoskeleton, it is possible to adopt adaptive (e.g., potential reduction of energy cost and musculoskeletal stress; Burnett et al., 2004) or maladaptive strategies (e.g., change of movements associated with discomfort or fear of injury). Repeated use of maladaptive strategies can limit the effectiveness of device use and acceptance, in addition to increasing the risk of injury and pain (Dankaerts et al., 2006). For example, among a group of soldiers with four to six hours of familiarization to an exoskeleton, Gregorczyk et al. (2010) observed significant changes in trunk, knee, and ankle ranges of motion and a higher rate of loading during walking. ...
OCCUPATIONAL APPLICATIONS
Military personnel are at greater risk of injuries due to frequent load carriage. Novel exoskeleton technology may have benefits for soldiers, such as reduced physical burden through load carriage support that may result in decreased metabolic cost, reduced fatigue, and lower risk of injuries during walking. However, as for most assistive devices, a familiarization period is likely necessary to obtain the full potential of the device. Our results show that the metabolic cost of walking (MWC) was initially increased significantly upon provision of the passive exoskeleton, though it returned to baseline values after a 9-day familiarization period. The exoskeleton remained effective after a three-month pause, with a MCW below baseline. These results suggest that to properly assess the assistance of an exoskeleton, a sufficient familiarization period should be mandatory.
... 32,33 The concept that sitting with poor posture can contribute to exacerbations of low back symptom is controversial. 6,11 Thus, the association between Table 2 Results of analysis of preventive treatment (ie, active break and postural shift) effects. ...
Introduction:
Neck and low back pain are significant health problem in sedentary office workers. Active break and postural shift interventions has been proved to reduce the incidence of new onset of both neck and low back pain.
Objectives:
To identify variables that moderate the effects of active breaks and postural shift interventions on the development of neck and low back pain in office workers.
Methods:
Using data from a 3-arm (active break, postural shift, and control group) cluster randomized controlled trial (N = 193), we evaluated the moderating effects of age, job position, education level, sex, perceived psychological work demands, number of working hours, and using a chair with lumbar support on the benefits of 2 interventions designed to prevent the development of neck and low back pain in office workers. Moderation analyses were conducted using the Hayes PROCESS macro, with post hoc Johnson-Neyman techniques and logistic regressions.
Results:
Significant interactions between intervention groups and 3 moderators assessed at baseline emerged. For the prevention of neck pain, the effect of the active break intervention was moderated by the number of working hours and the effect of the postural shift intervention was moderated by the level of perceived psychological work demands and the number of working hours. For the prevention of low back pain, the effect of postural shift intervention was moderated by having or not having a chair with lumbar support.
Conclusions:
The study findings can be used to help determine who might benefit the most from 2 treatments that can reduce the risk of developing neck and low back pain in sedentary workers and may also help us to understand the mechanisms underlying the benefits of these interventions.
Background/Objectives: The assessment of relationships between trunk muscle activity and thoraco-lumbar movements during sagittal bending has demonstrated that low back pain (LBP) subgroups (flexion pattern and active extension pattern motor control impairment) reveal distinct relationships that differentiate these subgroups from control groups. The study objective was to establish whether such relationships exist during various daily activities. Methods: Fifty participants with non-specific chronic low back pain (NSCLBP) (27 flexion pattern (FP), 23 active extension pattern (AEP)) and 28 healthy controls were recruited. Spinal kinematics were analysed using 3D motion analysis (Vicon™, Oxford, UK) and the muscle activity recorded via surface electromyography during a range of activities (box lift, box replace, reach up, step up, step down, stand-to-sit, and sit-to-stand). The mean sagittal angles for upper and lower thoracic and lumbar regions were correlated with normalised mean amplitude electromyography of bilateral transversus abdominis/internal oblique (IO), external oblique (EO), superficial lumbar multifidus (LM), and erector spinae (ES). Relationships were assessed via Pearson correlations (significance p < 0.01). Results: In the AEP group, increased spinal extension was associated with altered LM activity during box-replace, reach-up, step-up, and step-down tasks. In the FP group, increased lower lumbar spinal flexion was associated with reduced muscle activation, while increased lower thoracic flexion was associated with increased muscle activation. The control group elicited no significant associations. Correlations ranged between −0.812 and 0.754. Conclusions: Differential relationships between muscle activity and spinal kinematics exist in AEP, FP, and pain-free control groups, reinforcing previous observations that flexion or extension-related LBP involves distinct motor control strategies during different activities. These insights could inform targeted intervention approaches, such as movement-based interventions and wearable technologies, for these groups.
Preserving lumbar lordotic curvature (LLC) is considered an important strategy for both managing low back pain (LBP) and preventing its exacerbation; however, this approach has traditionally been limited to postural education. This study aimed to evaluate the effectiveness of a real-time biofeedback system that uses inertial sensors, and to compare its impact across various activities. Ten male participants with LBP wore sensor-equipped clothing while performing four daily activities commonly associated with an increased risk of LBP, under varying conditions of auditory feedback and postural education. The relative angles from the sensors were monitored in real-time as lumbar lordotic angle (LLA), with alarms triggered when LLA values dropped below a preset threshold. The impact of increasing LLA was assessed through regression analysis. For continuous flexion activities, such as sitting and mopping, auditory feedback significantly increased LLA by 10.2° and 10.5°, respectively (p < 0.001 for both). For repeated flexion tasks, such as picking-up and squatting, auditory feedback showed less or no effect compared with postural education. The feedback increased LLA by 5.8° in the picking-up task (p < 0.001), but was ineffective in squatting. These findings suggest that real-time biofeedback may be more effective in continuous flexion, whereas it appears to be limited in repetitive flexion.
Age is associated with increased tissue stiffness and a higher risk of low back pain, particularly in older, sedentary workers who spend long periods sitting. This study explored how trunk stiffness changes with age and its relationship with posture during prolonged sitting in a sample of 37 women aged 20-65 years. Age was assessed as both Chronological Age and Fitness Age, with trunk stiffness measured using a passive trunk flexion apparatus. Participants sat at a computer workstation for 60 minutes, and spine posture was recorded every 10 minutes. The study found that trunk stiffness significantly increased with age, especially when considering Fitness Age (r = 0.517, p = 0.003). Additionally, trunk stiffness was negatively correlated with spine motion during sitting (r = -0.435, p = 0.023). These findings suggest that workers with poorer health move less while sitting and could be more susceptible to the deleterious effects of sedentary work.
Background
The identification of back muscle dysfunction is a prerequisite for successful rehabilitation. Therefore, surface electromyography can be used for diagnostic and evaluative purposes. However, data quality highly depends on a) variance and inaccuracies in methodological procedures and b) on time-dependent changes, particularly in complex conditions such as chronic low back pain.
Objective
To assess intra-day, short-term and long-term reliability of a protocol designed for electromyographic measurements of the paraspinal muscles.
Methods
Three everyday tasks were selected for measurement in two healthy populations (mean age (years): 26.25/30.49 (SD: 7.05/11.03), sex-balanced). The procedure follows a detailed protocol (e.g., including ultrasound, electrode placement, movement commands). Intraclass correlation coefficient (ICC), standard error of measurement (SEM) and minimum detectable change (MDC) were calculated.
Results
Prone extension task demonstrated excellent test-retest agreement in all timespans (ICC = 0.92–0.96, SEM = 6.08–8.11, MDC = 16.85–22.49). Forward bending reliability ranged from moderate in long-term (ICC = 0.68–0.71, SEM = 1.98–2.52, MDC = 5.48–6.99) to good in intra-day (ICC = 0.76–0.89, SEM = 1.73–2.15, MDC = 4.79–5.95) to excellent in short-term assessment (ICC = 0.97, SEM = 1.07–1.21, MDC = 2.96–3.34). Sitting task showed the lowest test-retest agreement ranging between good to moderate in intra-day (ICC = 0.60–0.77, SEM = 1.22–1.26, MDC = 1.61–3.48)) and short-term reliability (ICC = 0.50–0.75, SEM = 1.24–2.06, MDC = 0.62–4.04) and moderate in long-term reliability (ICC = 0.65–0.71, SEM = 1.43–1.85, MDC = 3.95–5.12).
Conclusion
Using standardized procedures, surface electromyography can provide reliable data for practitioners in low back pain rehabilitation. Timespan had a limited influence on reliability compared to the type of task performed.
The role of posture in spinal pain is unclear which might be linked to characteristics of postural outcome measures. This systematic scoping review mapped the clinical utility of postural outcome tools for spinal pain. Following Joanna Briggs Institute framework, twelve bibliographic databases were searched until 8 th August 2023. Article selection, characterisation/mapping and synthesis using qualitative content analysis were performed by two independent reviewers. Clinical utility was defined by psychometric and clinimetric criteria. 85 eligible studies were identified from 89 publications. Twenty-eight distinct postural outcome tools plus bespoke measures were identified. Most tools were sophisticated computer-based electronic devices or complex time-consuming questionnaires, with limited applicability in non-occupational settings. Clinical utility domains most achieved were construct validity and inter/intra-rater reliability. Tools being underpinned by the biopsychosocial model of pain, sensitivity to clinical change, and predictive validity were the least achieved. Tools had limited clinical utility and were based on postural-structural-biomechanical pain model.
Purpose:
Systematic review and meta-analysis to examine common static postural parameters between participants with and without low back pain (LBP).
Methods:
Systematic search on the PubMed, CINAHL, Embase and SCOPUS databases using keywords 'posture' and 'low back pain'. Observational studies comparing static postural outcomes (e.g. lumbar lordosis) between participants with and without LBP were included. Two independent reviewers conducted screening, data extraction and quality assessment. Methodological quality was assessed using Joanna Briggs Institute's critical appraisal tools.
Results:
Studies included in review = 46 (5,097 LBP; 6,974 controls); meta-analysis = 36 (3,617 LBP; 4,323 controls). Quality of included studies was mixed. Pelvic tilt was statistically significantly higher in participants with LBP compared to controls (n = 23; 2,540 LBP; 3,090 controls; SMD:0.23, 95%CI:0.10,0.35, p < 0.01, I2=72%). Lumbar lordosis and sacral slope may be lower in participants with LBP; pelvic incidence may be higher in this group; both were not statistically significant and the between study heterogeneity was high. Thoracic kyphosis and leg length discrepancy showed no difference between groups.
Conclusions:
Lumbopelvic mechanisms may be altered in people with LBP, but no firm conclusions could be made. Pelvic tilt appeared to be increased in participants with LBP. Postural variable measurement needs standardisation. Better reporting of study characteristics is warranted.Implications for rehabilitationLumbo pelvic parameters especially pelvic tilt may be altered in people with low back pain, although no firm conclusion could be made due to the high heterogeneity between studies.Postural assessment within low back pain rehabilitation may therefore require an individualistic approach.
Background
The purpose of this study was to establish a prediction model for classifying the presence of flexion pattern chronic low back pain (CLBP) in office workers, including physical, individual, psychological, and occupational factors.
Methods
Ninety-five office workers (48 workers with CLBP and 47 workers without CLBP) participated in this study. Hip flexion ROM (HFR), knee extension ROM, knee extension ROM with ankle dorsiflexion, hip internal rotation ROM (HIR), hip flexor strength, pelvic posterior tilt angle (PPTA) in habitual sitting, and trunk extensor endurance were measured. Twelve variables (9 physical variables and age, sex, body mass index, Beck Depression Index, and working duration) were used to develop the prediction model for the presence of flexion pattern CLBP using logistic regression.
Results
The probability of the presence of flexion pattern CLBP significantly decreased with an odds ratio of HFR 0.884 (95% confidence interval [CI] = 0.817―0.957) and HIR 0.860 (95% CI = 0.799―0.926), but it increased with an odds ratio of PPTA in habitual sitting 1.190 (95% CI = 1.058―1.339). Our model showed acceptable accuracy of 82.1% and an area under the receiver operating characteristics curve of 0.898
Conclusions
HFR, HIR, and PPTA in habitual sitting could serve as guidelines for preventing and managing flexion pattern CLBP in office workers.
Background
Knowledge about factors affecting functional disability in patients with non-specific chronic low back pain (NSCLBP) is helpful in guiding treatment, but there has been little systematic research on this topic. This study aimed to identify independent factors contributing to functional disability in NSCLBP patients especially the impact of sagittal parameters and body postures in work, learning, and daily life.
Methods
Sociodemographic data, sagittal parameters, Oswestry Disability Index (ODI), Numeric Rating Scale (NRS), and 36-item Short Form Health Survey (SF-36) of NSCLBP patients were collected. Patients were divided into a low-functional disability group (ODI ≤ 20) and a high-functional disability group (ODI > 20), and the ODI was converted to ranked ODI (RODI) accordingly. Sociodemographic data, sagittal parameters, NRS, and SF-36 were compared by univariate analysis between both groups. A correlation analysis of the aforementioned factors with the RODI was conducted. The sociodemographic data and sagittal parameters related to the RODI were analyzed by logistic regression to select potential RODI-associated factors. The level of significance was set at P < 0.05.
Results
Age, educational background, daily main posture while working or learning (DMPWL), daily standing time while working or learning (DSTTWL), daily sitting time while resting (DSITR), sacral slope–pelvic tilt (SS-PT), spinosacral angle (SSA), NRS, and SF-36 (except mental health, MH) were different between the two groups (P < 0.05). Correlation analysis showed that they were related to the RODI (P < 0.05). The logistic regression analysis indicated that the regression coefficients of a college degree, postgraduate diploma, DSITR, and SSA were (B = −0.197; P = 0.003), (B = −0.211; P = 0.006), (B = −0.139; P = 0.039), and (B = −0.207; P = 0.001), respectively, and the odds ratio (OR) and 95% confidence interval (CI) were 0.489 (0.308; 0.778), 0.299 (0.125; 0.711), 0.875 (0.772; 0.993), and 0.953 (0.925; 0.981), respectively.
Conclusion
Educational background, DSITR, and SSA are independent factors affecting functional disability in NSCLBP patients. NSCLBP patients with a lower educational background, shorter DSITR, or smaller SSA should be taken into account in clinical practice and therapeutic choices. Extending sitting time for rest and the avoidance of a forward-leaning standing position are beneficial for reducing functional disability in NSCLBP.
Background
Identifying altered trunk control is critical for treating extension-related low back pain (ERLBP), a common subgroup classified by clinical manifestations. The changed coordination of trunk muscles within this group during particular trunk tasks is still not clearly understood.
Objectives
The objective of this study is to investigate trunk muscle coordination during 11 trunk movement and stability tasks in individuals with ERLBP compared to non-low back pain (LBP) participants.
Methods
Thirteen individuals with ERLBP and non-LBP performed 11 trunk movement and stability tasks. We recorded the electromyographic activities of six back and abdominal muscles bilaterally. Trunk muscle coordination was assessed using the non-negative matrix factorization (NMF) method to identify trunk muscle synergies.
Results
The number of synergies in the ERLBP group during the cross-extension and backward bend tasks was significantly higher than in the non-LBP group (p<0.05). The cluster analysis identified the two trunk synergies for each task with strikingly similar muscle activation patterns between groups. In contrast, the ERLBP group exhibited additional trunk muscle synergies that were not identified in the non-LBP group. The number of synergies in the other tasks did not differ between groups (p>0.05).
Conclusion
Individuals with ERLBP presented directionally specific alterations in trunk muscle synergies that were considered as increased coactivations of multiple trunk muscles. These altered patterns may contribute to the excessive stabilization of and the high frequency of hyperextension in the spine associated with the development and persistence of ERLBP.
italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">Body language
refers to the unspoken communication conveyed through human body actions like body movements and postures, limb gestures, and facial and other bodily expressions. It acts as a transparent medium, exposing an individual’s emotions, attitudes, true thoughts, intentions, and physical and mental health states. A person may express pain using hand movements or other bodily cues, their facial expressions potentially offering insights into the intensity of the pain. Additionally, various diseases and pains can induce abnormalities in body movements, postures, and expressions, signaling distress or discomfort. Therefore, investigating the cause-effect relationships between diseases/pains and patients’ abnormal body language holds significant relevance, promising to enhance our understanding and management of these conditions. This importance has been reflected in numerous healthcare and artificial intelligence (AI) research articles. AI studies investigate this and related topics by detecting, recognizing, and analyzing patients’ abnormal activities and body actions using machine-learning techniques. However, most AI studies do not consider comprehensive domain knowledge that describes a complete and accurate list of patients’ abnormal actions caused by a disease or pain. Though these results appear consistent and stable from an AI outlook, they fall short when viewed through the prism of healthcare, primarily because the limited domain knowledge incorporated in the AI studies makes the findings partially incomplete. To overcome these drawbacks, this paper comprehensively reviews healthcare and medical studies centered on patients’ body language from an AI outlook. It presents a thorough descriptive and exploratory analysis of the findings, yielding a more accurate and comprehensive understanding of the causational connections between diseases and abnormal body actions and the strength of the evidence supporting these connections. The analysis enables us to define “disease-to-abnormality” and “abnormality-to-disease” mappings that result in building exhaustive and accurate lists of abnormal body actions induced by diseases and pains as well as lists of diseases and pains causing particular abnormal body actions. The generation of these lists is assisted by the concepts of “correlation strength index” and “strongly correlated selection” defined in this paper. The paper’s results have significant implications for developing machine learning systems that can more accurately analyze patients’ physical and mental health states, correctly identify external signs and symptoms of diseases, and effectively monitor health conditions.
Background:
Understanding postural control in low back pain (LBP) subgroups can help develop targeted interventions to improve postural control. The studies on this topic are limited. Therefore, the primary purpose of this study was to compare the postural control of LBP subgroups with healthy individuals during overhead load lifting and lowering.
Methods:
In this cross-sectional study, the participants were 52 with LBP and 20 healthy. The LBP patients were classified based on the O'Sullivan classification system into 21 flexion patterns and 31 active extension patterns. The participants lifted the box from their waists to their overheads and lowered it to their waists. Changes in postural control parameters were measured with a force plate system.
Results:
The results of the analysis of variance showed that during load lifting, the mediolateral phase plane (p = .044) and the mean total velocity (p = .029) had significant differences between flexion patterns and healthy. Also, the load-lowering results showed that active extension patterns, compared with healthy, had significant differences in the anteroposterior-mediolateral phase plane (p = .042). The patients showed less postural sway than the healthy.
Conclusions:
The results in this work highlight the importance of identifying the homogenous subgroups in LBP and support the classification of heterogeneous LBP. Different subgroups exhibit different postural control behaviors. These behaviors can be due to the loading of various tissues during different tasks.
Background:
Sedentary work may lead to low back pain. In particular, a slumped sitting position may exacerbate low back pain because of tissue damage caused by excessive lumbar flexion and posterior pelvic tilting. Subjects with low back pain may have excessive changes in the lumbopelvic posture and back muscle activity in the sitting position.
Objective:
The purpose of this study was to compare the effects of vibration-based biofeedback using a motion sensor belt and no biofeedback on multifidus (MF) muscle activity and pelvic tilt angle during typing.
Methods:
Thirty subjects with low back pain accompanied by hip flexion limitation (15 each in the biofeedback and non-biofeedback groups) were enrolled. Electromyography was used to investigate MF muscle activity before and after typing for 30 min. Pelvic tilt was measured after typing in a sitting position for 30 min. Independent t-tests were used to compare MF muscle activity, and pelvic and second sacrum tilt angles, between the biofeedback and non-biofeedback groups.
Results:
After typing for 30 min, changes in MF muscle activity (11.45% and -7.19% for the biofeedback and nonbiofeedback groups, respectively) and pelvic and second sacrum tilt angles (3.15∘ and 4.12∘ for the biofeedback group and -11.05∘ and -18.16∘ for the non-biofeedback group, respectively) were significantly smaller in the biofeedback than non-biofeedback group (p< 0.05).
Conclusion:
Vibration-based biofeedback minimizes the reduction in MF muscle activity and changes in pelvic and second sacrum tilt angles during typing in individuals with low back pain accompanied by hip flexion limitation.
Objective:
This study aimed to compare dynamic postural control between individuals with and without chronic low back pain (LBP) through load lifting and lowering.
Methods:
This cross-sectional study included 52 male patients with chronic LBP (age: 33.37 ± 9.23 years) and 20 healthy male individuals (age: 31.75 ± 7.43 years). The postural control parameters were measured using a force plate system. The participants were instructed to stand barefoot (hip-width apart) on the force plate and lift a box (10% of the weight of the participants) from the waist height to overhead and then lower it from overhead to waist height. The interaction between the groups and tasks was determined using a 2-way repeated-measures analysis of variance.
Results:
There was no significant interaction between the groups and tasks. Regardless of the groups, postural control parameters including amplitude (P = .001) and velocity (P < .001) in anterior-posterior (AP) direction, phase plane in medial-lateral (ML) direction (P = .001), phase plane in AP-ML direction (P = .001), and the mean total velocity (P < .001) were lesser during the lowering compared with lifting. The results indicated that, regardless of the tasks, the postural control parameters including velocity (P = .004) and phase plane in AP direction (P = .004), velocity in ML direction (P < .001), phase plane (AP-ML) (P = .028), and mean total velocity (P = .001) in LBP were lesser compared with the normal group.
Conclusion:
Different tasks affected postural control differently in patients with LBP and healthy individuals. Moreover, postural control was more challenged during the load-lowering than the load-lifting task. This may have been a result of a stiffening strategy. It may be that the load-lowering task might be considered as a more influential factor for the postural control strategy. These results may provide a novel understanding of selecting the rehabilitation programs for postural control disorders in patients.
Introduction:
Studies analyzing postures and mobility of the thoracic spine in the context of cervicogenic headache are missing. Insight in these parameters is needed since the cervical and thoracic spine are biomechanically related.
Objective:
To compare self-perceived optimal and habitual postures, active-assisted maximal range of motion, and repositioning error of the upper-thoracic and lower-thoracic spine between a cervicogenic headache-group and matched healthy control-group before and after a 30 min-laptop-task.
Methods:
A non-randomized longitudinal design was used to compare thoracic postures and mobility between 18 participants with cervicogenic headache (29-51 years) and 18 matched healthy controls (26-52 years). Outcomes were: self-perceived optimal and habitual postures, active-assisted maximal range of motion, and repositioning error of the upper-thoracic and lower-thoracic spine evaluated in sitting with a 3D-Vicon motion analysis system.
Results:
Habitual upper-thoracic postures in the cervicogenic headache-group were significantly (p = .04) less located toward the maximal range of motion for flexion compared to the control-group, self-perceived optimal upper-thoracic posture was significantly (p = .004) more extended in the cervicogenic headache-group compared to the control-group, and self-perceived optimal lower-thoracic posture could not be reestablished in the cervicogenic headache-group after the laptop-task (p = .009).
Conclusion:
Thoracic postures differ between a cervicogenic headache-group and control-group. These differences were detected by expressing the habitual thoracic posture relative to its maximal range of motion, and by analyzing the possibility of repositioning the thoracic spine after a headache provoking activity. Longitudinal studies are needed to determine the contribution of these musculoskeletal dysfunctions to the pathophysiology of cervicogenic headache.
Zusammenfassung
Bei muskuloskelettalen Beschwerden gibt es wissenschaftlich nachgewiesen keine wirkungsvollere Behandlung als eine auf Bewegung und Übungen basierende Therapie. Zur Diagnostik gehören das Beurteilen der Bewegungsqualität und Tests, die Aufschluss über mangelnde Bewegungskontrolle und Bewegungsdysfunktionen geben. Angepasste Übungen, Training und ein verbessertes Bewusstsein für das eigene Bewegungsverhalten sowie eine verbesserte Wahrnehmung für den eigenen Körper durchbrechen bei vielen Betroffenen muskuloskelettale Schmerzmechanismen und führen zurück in ein schmerzfreies Leben. Die folgenden Artikel zeigen exemplarisch am Beispiel Rückenschmerzen die Bedeutung von Bewegungskontrolle und Körperwahrnehmung.
Transcranial magnetic stimulation (TMS) has revealed differences in the motor cortex (M1) between people with and without low back pain (LBP). There is potential to reverse these changes using motor skill training, but it remains unclear whether changes can be induced in people with LBP or whether this differs between LBP presentations. This study (1) compared TMS measures of M1 (single and paired-pulse) and performance of a motor task (lumbopelvic tilting) between individuals with LBP of predominant nociceptive (n = 9) or nociplastic presentation (n = 9) and pain-free individuals (n = 16); (2) compared these measures pre- and post-training; and (3) explored correlations between TMS measures, motor performance, and clinical features. TMS measures did not differ between groups at baseline. The nociplastic group undershot the target in the motor task. Despite improved motor performance for all groups, only MEP amplitudes increased across the recruitment curve and only for the pain-free and nociplastic groups. TMS measures did not correlate with motor performance or clinical features. Some elements of motor task performance and changes in corticomotor excitability differed between LBP groups. Absence of changes in intra-cortical TMS measures suggests regions other than M1 are likely to be involved in skill learning of back muscles.
Bolesť chrbta je najčastejším ochorením, ktoré postihuje veľké množstvo ľudí na celom svete. Diagnostikované je už aj u mladej generácii a výrazne postihuje ľudí nad 45 rokov. Ide o 5. najčastejšie ochorenie, ktoré vedie k hospitalizácii. Našim cieľom bolo vytvorenie naratívnej prehľadovej štúdie v oblasti vertebrogénnych porúch a možnosti korekcie pomocou rôznych typov cvičení pre bežnú populáciu. Prehľad je založený na randomizovaných kontrolovaných štúdiách (RCTs), ktoré overili účinnosť cvičebného programu pri korekcii vertebrogénnych porúch. Primárne a sekundárne štúdie boli vyhľadávané v databázach PubMed, Web of Science a Scopus. Do prehľadu boli zahrnuté štúdie, ktoré spĺňali nasledujúce kritériá: vek účastníkov: nad 18 rokov; všeobecná populácia; účastníci so súčasnými alebo predchádzajúcimi epizódami bolesti chrbta alebo bez nich; typ štúdie: randomizované kontrolované štúdie (RCTs); typ intervencie: cvičebný program zameraný na nápravu vertebrogénnych porúch; jazyk štúdie: angličtina. Štúdie boli vyhľadávané v období 2010-2022. V počiatočnom vyhľadávaní sme zistili 262 RCTs (2763 účastníkov), ale do prehľadu bolo zahrnutých 33 RCTs, ktoré splnili naše vopred stanovené kritériá. Zistili sme, že štúdie overili vplyv cvičenia na bolesti chrbta (9 pilates, 6 joga, 6 silové cvičenia; 6 stabilizačné a mobilizačné cvičenia; 4 tréning motorických zručností; 3 strečing; 1 vibračný tréning celého tela; 1 vodný strečing). Väčšina hodnotených štúdií (63 %) skúmala populácie s bolesťami v oblasti driekovej chrbtice. Najčastejším typom skúmaného cvičenia bolo pilates (25 %), ďalej joga (17 %), silové cvičenia (17 %), stabilizačné a mobilizačné cvičenia (17 %), tréning motorických zručností (11 %), strečing (8 %), strečing vo vode (3 %), tréning vibrácií celého tela (3 %). Najviac spomínanými formami cvičenia na korekciu vertebrogénnych porúch chrbtice boli cvičenia pilates, jogové cvičenia, posilňovacie cvičenia a stabilizačné a mobilizačné cvičenia. Na základe skúmaných štúdií existujú určité dôkazy o dĺžke trvania cvičebného programu, ktoré naznačujú v priemere 11 týždňov pilatesu, 8 týždňov jogy, 12 týždňov silového tréningu a 12,5 týždňa stabilizácie a mobilizačných cvičení. Súčasné závery o náprave vertebrogénnych porúch sú nejasné a nejednotné.
The identification of relevant and valid biomarkers to distinguish patients with non-specific chronic low back pain (NSCLBP) from an asymptomatic population in terms of musculoskeletal factors could contribute to patient follow-up and to evaluate therapeutic strategies. Several parameters related to movement impairments have been proposed in the literature in that respect. However, most of them were assessed in only one study, and only 8% were evaluated in terms of reliability, validity and interpretability. The aim of this study was to consolidate the current knowledge about movement biomarkers to discriminate NSCLBP patients from an asymptomatic population. For that, an experimental protocol was established to assess the reliability, validity and interpretability of a set of 72 movement biomarkers on 30 asymptomatic participants and 30 NSCLBP patients. Correlations between the biomarkers and common patient reported outcome measures were also analysed. Four biomarkers reached at least a good level in reliability (ICC ≥ 0.75) and validity (significant difference between asymptomatic participants and NSCLBP patients, p ≤ 0.01) domains and could thus be possibly considered as valuable biomarkers: maximal lumbar sagittal angle, lumbar sagittal angle range of motion, mean lumbar sagittal angular velocity, and maximal upper lumbar sagittal angle during trunk sagittal bending. These four biomarkers demonstrated typically larger values in asymptomatic participants than in NSCLBP patients. They are in general weakly correlated with patient reported outcome measures, arguing for a potential interest in including related musculoskeletal factors in the establishment of a valuable diagnosis and in guiding treatment response.
Background:
Sway-back posture in the sagittal profile is a commonly adopted poor standing posture. Although the terms, definitions, and adverse health problems of sway-back posture are widely used clinically, few studies have quantified sway-back posture.
Objective:
To investigate spinal sagittal alignment in sway-back posture while standing based on global and regional angles using inertial measurement units (IMUs).
Methods:
This cross-sectional study recruited 30 asymptomatic young adults. After measuring the sway angle while standing, the participants were divided into sway-back and non-sway-back groups (normal thoracic group). Each participant stood in a comfortable posture for 5 seconds with IMUs at the T1, T7, T12, L3, and S2 levels. Then, we measured the global and regional lumbar and thoracic angles and sacral inclination in the standing position.
Results:
Although there was no difference in the global lumbar angle, there was a difference in regional lumbar angles between the two groups. The normal thoracic group had balanced lumbar lordosis between the upper and lower lordotic arcs, whereas the sway back group tended to have a flat upper lumbar angle and increased lower lumbar angle.
Conclusion:
It is useful to assess the global and regional angles in the spinal sagittal assessment of individuals with sway-back posture.
Objective:
Biomechanics represents the common final output through which all biopsychosocial constructs of back pain must pass, making it a rich target for phenotyping. To exploit this feature, several sites within the NIH Back Pain Consortium (BACPAC) have developed biomechanics measurement and phenotyping tools. The overall aims of this paper were to: 1) provide a narrative review of biomechanics as a phenotyping tool; 2) describe the diverse array of tools and outcome measures that exist within BACPAC; and 3) highlight how leveraging these technologies with the other data collected within BACPAC may elucidate the relationship between biomechanics and other metrics used to characterize low back pain (LBP).
Methods:
The narrative review highlights how biomechanical outcomes can discriminate between those with and without LBP, as well as the severity of LBP. It also addresses how biomechanical outcomes track with functional improvements in LBP. Additionally, we present the clinical use case for biomechanical outcome measures that can be met via emerging technologies.
Results:
To answer the need of measuring biomechanical performance our results section describes the spectrum of technologies that have been developed and are being used within BACPAC.
Conclusion:
and future directions: The outcome measures collected by these technologies will be an integral part of longitudinal and cross-sectional studies conducted in BACPAC. Linking these measures with other biopsychosocial data collected within BACPAC increases our potential to use biomechanics as a tool for understanding the mechanisms of LBP, phenotyping unique LBP subgroups, and matching these individuals with an appropriate treatment paradigm.
Background
Picking objects off the floor is provocative for people with chronic low back pain (CLBP). There are no clinically applicable methods evaluating movement strategies for this task. The relationship between strategy and multidimensional profiles is unknown.
Objective
Develop a movement evaluation tool (MET) to examine movement strategies in people with CLBP (n = 289) picking a pencil off the floor. Describe those movement strategies, and determine reliability of the MET. Explore differences across multidimensional profiles and movement strategies.
Methods
An MET was developed using literature and iterative processes, and its inter-rater agreement determined. Latent class analysis (LCA) derived classes demonstrating different strategies using six movement parameters as indicator variables. Differences between classes across multidimensional profiles were investigated using analysis of variance, Kruskal-Wallis, or chi-squared tests.
Results
Six movement parameters were evaluated. There was substantial inter-rater agreement (Cohen’s Kappa = 0.39–0.79) across parameters. LCA derived three classes with different strategies: Class 1 (71.8%) intermediate trunk inclination/knee flexion; Class 2 (24.5%) greater forward trunk inclination, lower knee flexion; Class 3 (3.7%) lower forward trunk inclination, greater knee flexion. Pain duration differed across all classes (p ≤ .001). Time taken to complete forward bends differed between Class 3 and other classes (p = .024).
Conclusions
Movement strategies can be reliably assessed using the MET. Three strategies for picking lightweight objects off the floor were derived, which differed across pain duration and speed of movement.
A healthy spine is of utmost importance when it comes to our quality of life. Many aspects of our lives including posture, exercise, nutrition, smoking, sleep and stress impact the spine. A fundamental understanding of the anatomy of our spine and how various factors affect spine health is important. The tremendous rise in technology has also significantly impacted spine health. The various electronic devices are often used for prolonged periods of time in the same position by adults and children for work, school and entertainment. In addition, the recent global matter of the pandemic and the major shift of the working population from the office to the home has affected our spine health. This mostly revolves around suboptimal work environments and work stations. Maintaining a healthy lifestyle both at work and home is important in keeping our spine and bodies in optimal shape and condition.KeywordsSpineLow back painNeck painText neckLumbar spineCervical spinePostureErgonomicsWork stationSleep positionLifestyleExercise and spineSmoking and spineNutrition and spine
Introduction and aim: In the past few decades, exercise has been promoted with increasing interest for the treatment of back pain. Therefore, the present study aimed to investigate the effect of rehabilitation exercises with medicine beta balls on the directional and general contraction of ankle joint muscles in patients with low back pain during walking. Methods: The present study was a clinical trial. The statistical population was patients with low back pain in the age range of 20-30 years in Ardabil in 1399. Twenty men with low back pain were randomly divided into exercise and control groups. The intervention group performed 12 sessions of strengthening exercises of the central muscles of the body with the beta medicine ball. The activity of selected muscles was recorded during walking pre-and post-test in two groups. A two-way analysis of variance with repeated measures was used for statistical analysis. Results: The results showed that the interactive effect of time and group on the directional contraction values of the ankle joint during the middle phase was significant (P = 0.020). Post hoc test showed that the values of all directional contraction of the ankle joint increased significantly during the middle phase in the experimental group. Conclusions: Increasing the values of directional contraction after the training period during the middle phase of reliance in the experimental group can be associated with more joint stability and less vulnerability
Background
Low back pain patients suffer from balance disturbance. Balance allows a person to interact with the surrounding environment and to do his daily activities. As recent technology has facilitated patient monitoring and enhanced our ability to monitor patients remotely, smartphone apps have been developed to achieve this goal. There are various balance assessment instruments used nowadays. It may be subjective or objective assessments. This study was applied to verify if the measurements of balance Y-MED smartphone applications are valid and reliable compared to the HUMAC balance board in order to offer easy, fast, cost-effective, and time-effective valid and reliable balance assessment that can be used in a clinical setting.
Methods
Fifty-four patients (12 males and 42 females) with chronic mechanical low back pain for more than 3 months was volunteered to participate in the current study with an age range of 25–60 years and BMI range of 18–34 kg/m ² . Compared with the HUMAC balance board, the validity of the balance Y-MED smartphone application is evaluated, and the test-retest reliability of the balance Y-MED smartphone application is obtained by the same examiner 3 times.
Results
For concurrent validity, the correlations between balance measurements by Y-MED smartphone application and HUMAC balance board were not significant in both eyes open ( r = − 0.12, p = 0.38) and eyes closed ( r = 0.26, p = 0.054). The smartphone application showed poor test-retest reliability measurement of balance with eyes open; (ICC was 0.279, with 95% CI − 0.117–0.554) and with eyes closed (ICC was − 0.159, with 95% CI − 0.814–0.287).
Conclusions
According to the evaluation scheme selected in this study, the researchers were unable to confirm the validity of the balance Y-MED smartphone application in the balance assessment of patients with mechanical chronic low back pain. More than that, the balance Y-MED smartphone application has been shown poor score reliability. This makes it inaccurate for use in assessment balance.
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.
The organization of collagen in the supraspinous, interspinous, and longitudinal ligaments, as well as the ligamenta flava, in lumbar spines from human cadavers has been investigated by polarized light microscopy, scanning electron microscopy, and x-ray diffraction. These experiments were performed on ligaments in situ, with their bony attachments undisturbed, and on excised ligaments at a range of applied strains. Results were related to the composition (investigated by standard histologic techniques) and gross structures (investigated by light microscopy) of the ligaments. More importantly, the results were related to the mechanical properties of the ligaments, which include stiffness, failure conditions, stress relaxation, and hysteresis. Where necessary, results were supplemented by or compared with those obtained from pig ligaments. Mechanical properties were related to postural changes by ligament strains induced in cadaveric specimens, using results from the literature. Thus, ligament structures could be related to their physiologic functions.
The efficacy of specific exercise interventions that advocate training the co-contraction of the deep abdominal muscles with lumbar multifidus for treating chronic back pain conditions has not been tested. A randomized controlled trial involving 42 subjects with a specific chronic back pain condition investigated whether this form of intervention results in changes to the ratio of activation of the internal oblique relative to the rectus abdominis. Data were collected before and after the intervention, using surface electromyography, while subjects performed different abdominal maneuvers. Subjects were randomly allocated to either a specific exercise group or control group. Following intervention, the specific exercise group showed a significant (p < 0.05) increase in the ratio of activation of the internal oblique relative to the rectus abdominis. The control group showed no significant change. The study findings provide evidence that the conscious and automatic patterns of abdominal muscle activation can be altered by specific exercise interventions.
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.
To examine the association between self reported physical workload and low back pain (LBP) in younger twins. To investigate whether genetic factors interact with physical workload in relation to LBP.
A twin control study was performed within a population based twin register using 1910 complete monozygotic (MZ) and same sexed dizygotic (DZ) twin pairs aged 25-42 and discordant for LBP. LBP in the affected twins was divided into two groups: "LBP for </=30 days during the past year", and "LBP for >30 days during the past year". Physical workload was divided into four categories: "sitting", "sitting/walking", "light physical", and "heavy physical". Data were analysed in a matched design using conditional logistic regression. MZ and DZ twins were analysed separately and together in order to determine possible genetic influences in relation to physical workload and LBP.
Statistically significant graded relations were found for increasing workload and LBP of longer duration but not for LBP of shorter duration (</=30 days during the past year). In both LBP groups the "sitting" and "sitting/walking" groups were not statistically different. MZ and DZ twins did not differ significantly with respect to LBP in the various workload groups.
There is evidence for a dose-response relation between physical workload and LBP of longer duration. Attention to clinically relevant subgroups based on duration, for example, is necessary in epidemiological studies dealing with LBP. Physical workload might be more important than genetic factors in LBP.
Musculoskeletal conditions are a major burden on individuals, health systems, and social care systems, with indirect costs being predominant. This burden has been recognized by the United Nations and WHO, by endorsing the Bone and Joint Decade 2000-2010. This paper describes the burden of four major musculoskeletal conditions: osteoarthritis, rheumatoid arthritis, osteoporosis, and low back pain. Osteoarthritis, which is characterized by loss of joint cartilage that leads to pain and loss of function primarily in the knees and hips, affects 9.6% of men and 18% of women aged > 60 years. Increases in life expectancy and ageing populations are expected to make osteoarthritis the fourth leading cause of disability by the year 2020. Joint replacement surgery, where available, provides effective relief. Rheumatoid arthritis is an inflammatory condition that usually affects multiple joints. It affects 0.3-1.0% of the general population and is more prevalent among women and in developed countries. Persistent inflammation leads to joint destruction, but the disease can be controlled with drugs. The incidence may be on the decline, but the increase in the number of older people in some regions makes it difficult to estimate future prevalence. Osteoporosis, which is characterized by low bone mass and microarchitectural deterioration, is a major risk factor for fractures of the hip, vertebrae, and distal forearm. Hip fracture is the most detrimental fracture, being associated with 20% mortality and 50% permanent loss in function. Low back pain is the most prevalent of musculoskeletal conditions; it affects nearly everyone at some point in time and about 4-33% of the population at any given point. Cultural factors greatly influence the prevalence and prognosis of low back pain.
Background:
Diagnoses and treatments based on movement system impairment syndromes were developed to guide physical therapy treatment.
Objectives:
This masterclass aims to describe the concepts on that are the basis of the syndromes and treatment and to provide the current research on movement system impairment syndromes.
Results:
The conceptual basis of the movement system impairment syndromes is that sustained alignment in a non-ideal position and repeated movements in a specific direction are thought to be associated with several musculoskeletal conditions. Classification into movement system impairment syndromes and treatment has been described for all body regions. The classification involves interpreting data from standardized tests of alignments and movements. Treatment is based on correcting the impaired alignment and movement patterns as well as correcting the tissue adaptations associated with the impaired alignment and movement patterns. The reliability and validity of movement system impairment syndromes have been partially tested. Although several case reports involving treatment using the movement system impairment syndromes concept have been published, efficacy of treatment based on movement system impairment syndromes has not been tested in randomized controlled trials, except in people with chronic low back pain.
A new method for the non-invasive three-dimensional measurement of human lumbar movement is described. The electro-magnetic 3space Isotrak system was found to be accurate and reliable, having a total r.m.s. error for rotations of less than o·2°. The system was able to produce consistent plots of subjects' movement patterns and it is proposed that this system should be evaluated in respect of its discriminatory and predictive potential in clinical studies of low back disorders. It may then become a useful tool in the routine clinical assessment of patients with spinal disorders, providing a complete quantification of back kinematics quickly and efficiently.
Concepts of diagnosis and classification have a long history in medicine, while formal schemes of diagnostic classification in physical therapy are relatively new. Basic differences exist between medicine and physical therapy in the phenomena which are diagnosed and classified. However, similarities in the diagnostic and classification process provide an opportunity to learn from medicine as the process now evolves in physical therapy. This paper provides a brief history of the development of the concept of diagnostic classification in medicine and physical therapy. Difficulties associated with the process are described. Knowledge of these difficulties is used to analyze some of the evolving concepts of diagnostic classification in physical therapy, especially those related to orthopaedic physical therapy practice.
Knowledge of the incidence and prevalence of low back symptoms is useful to plan for hospital services and social welfare. In addition, such studies can give information about the importance of work factors and individual factors in the etiology and course of pack pain. The purpose of this brief survey is to summarize studies on the frequency of low back pain in Sweden, and to conclude from a few of the many investigations made to analyse relationships between back symptoms, work factors and individual factors. The paper is mainly concerned with low back symptoms, which are more important clinically than other back symptoms, at least in terms of sickness absence. The public insurance in Sweden comprises health insurance, basic retirement pension and supplementary retirement pension. The insurance is compulsory. All Swedish subjects and all foreign nationals domiciled in Sweden - adults and children alike - are covered. All subjects domiciled in Sweden and over 16 years of age must be registered with a Swedish local public insurance office. These offices are supervised by the National Social Insurance Board. The public insurance offices administer in addition the industrial injuries insurance, cash labour market assistance, family allowances, and student benefit and training grants. Due to its nature reports from the public insurance gives an almost complete picture of the health situation. These reports are based, however, on the data provided by doctors and the diseased.
This study compared the effects of sitting with portable supports in either a kyphotic or lordotic posture on low-back and referred pain. Two hundred ten patients with low-back and/or referred pain were randomly assigned to either a kyphotic posture or lordotic posture group. The kyphotic and lordotic postures were facilitated by the use of a flat foam cushion or lumbar roll, respectively. Pain location, back pain, and leg pain intensity were assessed over a 24-48-hour period under both standardized clinical settings and general sitting environments. When sitting with a lordotic posture, back and leg pain were significantly reduced and referred pain shifted towards the low back. This study demonstrates that in general sitting environments a lumbar roll results in: 1) reductions in back and leg pain; and 2) centralization of pain. These findings do not apply to patients with stenosis or spondylolisthesis, whose symptoms may be aggravated by use of a lumbar roll.
Introduction
The Need to Define Role and Function
The need to define the role and function of diagnosis in physical therapy practice stems from the importance of distinguishing this diagnosis from those made by other health care practitioners. Identifying the role and function of physical therapy diagnoses also should provide evidence that they have distinguishing characteristics, are limited to our body of knowledge and scope of practice, and are complementary to (and not in conflict with) diagnoses made by other health care practitioners. The current political-legal aspects of this issue mandate that the profession clearly communicate that the intention of the physical therapy diagnosis is not to infringe on the practice of others or to assume roles that are beyond the scope of our education and training.
These political-legal issues include the prerogative and extent of involvement of the physical therapist in the diagnostic process. Resolution of these issues is done within the legislative arena.
In the present work, the load-bearing role of the facet joints in a lumbar I2–3 segment is quantitatively determined by means of a three dimensional nonlinear finite element program. The analysis accounts for both material and geometric nonlinearities and treats the facet articulation as a nonlinear moving contact problem. The disc nucleus is considered as an inviscid incompressible fluid and the annulus as a composite of collagenous fibres embedded in a matrix of ground substance. The spinal ligaments are modelled as a collection of nonlinear axial elements. The loadings consist of axial compression and sagittal plane shears and bending moments, acting alone or combined.
429 patients with low back pain (LBP), from a total of 3,316 subjects belonging to 8 preselected occupations, have been investigated with regard to the medical history and symptomatology. The earliest age of onset of LBP occurred in bank clerks, heavy industry workers, farmers and nurses. The type of onset was sudden in all occupations with the exception of bank clerks in whom back discomfort was the presenting symptom. Weight lifting and bending were the most commonly incriminated causes of LBP. Trauma was an insignificant factor. Coughing and standing were the predominant aggravating factors, while changes of the usual occupational position generally relieved the pain. It is concluded that postural disorders, related to occupation, are an important causative agent for LBP and recommendations based on these facts are made.
Disorders of the lumbar spine are among the most common medical problems in western countries, affecting up to 80% of people at some time during their lives. The epidemiology and impact of six specific disorders of the lumbar spine are reviewed. These include prolapsed discs, disc degeneration, osteoarthrosis of the apophyseal joints, fractures and dislocations of vertebrae, osteoporosis, and spondylolisthesis. Various mechanical factors contribute to the causation of most of these disorders, but other underlying pathologic mechanisms are important as well. In light of the great impact of these conditions on society and on individuals, it is concluded that there is a considerable need for a greater allocation of resources for improvement in methods of prevention, diagnosis, and treatment.
Cadaveric lumbar intervertebral joints were loaded to simulate the erect standing posture (lordosis), and the erect sitting posture (slightly flexed). The results show that, after the intervertebral disc has been reduced in height by a period of sustained loading, the apophysial joints resist about 16 per cent of the intervertebral compressive forces in the erect standing posture, whereas in the erect sitting posture they resist none. The implications of this in relationship to degenerative changes and to low backache are discussed.
The role of epidemiology with respect to back pain in industry is to clarify the natural history and clinical course of the pain and to identify workplace factors and individual factors of importance. On the basis of knowledge obtained through epidemiologic research, preventive measures can be instituted and risk factors eliminated. This paper reviews epidemiological data accumulated over the past 30 years. The impact of back conditions on industry is emphasized.
The purpose of this study was to measure and describe postural aberrations in chronic and acute low back pain in search of predictors of low back pain. The sample included 59 subjects recruited to the following three groups: chronic, acute, or no low back pain. Diagnoses included disc disease, mechanical back pain, and osteoarthritis. Lumbar lordosis, thoracic kyphosis, head position, shoulder position, shoulder height, pelvic tilt, and leg length were measured using a photographic technique. In standing, chronic pain patients exhibited an increased lumbar lordosis compared with controls (p < .05). Acute patients had an increased thoracic kyphosis and a forward head position compared with controls (p < .05). In sitting, acute patients had an increased thoracic kyphosis compared with controls (p < .05). These postural parameters identified discrete postural profiles but had moderate value as predictors of low back pain. Therefore other unidentified factors are also important in the prediction of low back pain.
A global and segmental study on standing lateral radiographs of 100 volunteers and 100 patients who had low back pain was undertaken to further define sagittal plane alignment and balance. The volunteer control group and the patient group were matched for age, sex, and size.
Measurements and determinations made on the standing radiographs included the following: segmental and total lordosis L1-S1 (Cobb method); thoracic kyphosis; thoracic apex; plumbline dropped from the center of C7; and sacral inclination measured between the plumbline and a line drawn along the back of the proximal sacrum.
Segmental lordoses were significantly different between each motion segment in both groups. Approximately two-thirds of total lordosis occurred at the bottom two discs, i.e., L4-5 and L5-S1. Total lordosis was significantly less in the patients and was not age- or sex-related in either group. Patients tended to stand with less distal segmental lordosis, but more proximal lumbar lordosis, a more vertical sacrum and, therefore, more hip extension. This may be related to compensation as C7 sagittal plumb lines were comparable in both groups. Both groups had similar thoracic kyphosis. A much higher percentage of smokers was found in the low back pain patient population studied. Because of the significant amount of angulation in the lower lumbar spine, measurement of lordosis should include the L5-S1 motion segment and be done standing to better assess balance. Sacral inclination is a determinate of both standing pelvic rotation and hip extension. It is strongly correlated with segmental and total lordosis in both volunteers and patients.
Definitions of sagittal balance are provided as well as additional sagittal plane data by which to compare corrections and fusions for different spinal disorders.
Activity of the trunk muscles is essential for maintaining stability of the lumbar spine because of the unstable structure of that portion of the spine. A model involving evaluation of the response of the lumbar multifidus and abdominal muscles to leg movement was developed to evaluate this function.
To examine this function in healthy persons, 9 male and 6 female subjects (mean age = 20.6 years, SD = 2.3) with no history of low back pain were studied.
Fine-wire and surface electromyography electrodes were used to record the activity of selected trunk muscles and the prime movers for hip flexion, abduction, and extension during hip movements in each of those directions.
Trunk muscle activity occurring prior to activity of the prime mover of the limb was associated with hip movement in each direction. The transversus abdominis (TrA) muscle was invariably the first muscle that was active. Although reaction time for the TrA and oblique abdominal muscles was consistent across movement directions, reaction time for the rectus abdominis and multifidus muscles varied with the direction of limb movement.
Results suggest that the central nervous system deals with stabilization of the spine by contraction of the abdominal and multifidus muscles in anticipation of reactive forces produced by limb movement. The TrA and oblique abdominal muscles appear to contribute to a function not related to the direction of these forces.
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.
Narrative review and discussion of the selected literature.
To discuss some important methodologic challenges in low back pain research in primary care.
Many methodologic problems must be confronted when conducting low back pain research. Some of these problems are back pain specific or specific to the primary care setting.
Methodologic problems related to four research issues will be discussed: study designs, definition of low back pain, determinants of low back pain, and outcome assessment.
Two fundamentally different study designs are frequently used in low back pain research, namely observational studies and experimental studies. The definition of low back pain is typically restricted to a highly variables self-reported symptom, the sensation of pain in the back. There clearly is a need for an evidence-based classification system for low back pain. Because a tenable theoretical framework is lacking, it is difficult to know which determinants of low back pain should be quantified. Low back pain studies focus usually on health-related quality-of-life outcome parameters. The identification of the minimum clinically relevant changes for the most important outcome instruments needs further consideration.
In years to come, low back pain researchers are challenged to overcome some of these (and other) problems to enhance the quality of low back pain research in primary care.
Consensus process.
Reexamining and redirecting the research agenda for low back pain in primary care.
Most research, publications, and funding have traditionally been directed toward specialty and biologically oriented investigations of "spinal disorders" from biomedical and biomechanical perspectives. Beginning in the mid-1980s, primary care researchers began to investigate this field in earnest, focusing on lower back pain as a pain syndrome within an individual, family, and community context. Unfortunately, more progress has been made on what should not be done in diagnosing and treating lower back pain than on what should be done.
This was a modified group process designed to reach consensus among an international group of primary care lower back pain researchers.
Nearly all of the research priorities from the initial 1995 forum are still thought to be important, although only modest progress has been made on most of them. The priorities perceived to be the most feasible to investigate and the ones in which the greatest strides have been achieved are in methodologic rather than substantive areas. Identifying subgroups of people with lower back pain is still given top ranking in 1997, but the priorities have changed dramatically. Greater emphasis is given to finding predictors and risk factors for lower back pain chronicity, improving self-care strategies, and stimulating self-reliance. New items now make up 50% of the top 10 priorities. In general, the additions reflect a greater emphasis on expanding methodologic avenues of inquiry.
Methodologic advances, the enlistment of new techniques and disciplines, and redirected research efforts may facilitate progress in the diagnosis and treatment of lower back pain.
A controlled study with a 6-month follow-up period.
To find an explanation for the association between impairment in information processing, i.e., slow reaction times, and chronic low back trouble.
Low back trouble, chronic pain in general, and depression have been associated with impaired cognitive functions and slow reaction times. It is a common phenomenon that the preferred hand performs better than the nonpreferred hand in motor tasks. The authors hypothesized that chronic low back trouble hampers the functioning of short-term memory in a way that leads the preferred hand to loose its advantage over the nonpreferred hand, but that the advantage would be restored during the rehabilitation.
Sixty-one healthy control subjects and 68 patients with low back trouble participated in the study. Reaction times for the preferred and nonpreferred upper limbs were tested. A multiway analysis of covariance was used to examine the group, handedness, and rehabilitation effects on reaction times. The hypothesis was specifically tested with a third-degree interaction: group-handedness-rehabilitation.
A significant interaction among group, handedness, and rehabilitation was found (P = 0.05). At the beginning, the reaction times for the preferred hand were faster among the control subjects (P = 0.001), but not among the patients with low back trouble (P = 0.62). After the rehabilitation, the preferred hand was faster both among the control subjects (P = 0.001) and the patients with low back trouble (P = 0.0002). During the rehabilitation, back pain, psychological distress, and general disability decreased significantly among the patients with chronic low back trouble.
The results support the hypothesis that chronic low back trouble (i.e., pain, psychological distress, and general disability) hampers the functioning of short-term memory, which results in decreased speed of information processing among patients with chronic low back trouble.
Single-group, posttest only, using a sample of convenience.
To measure the repositioning error of subjects with low back pain for lumbar sagittal movement using a simple kinesthetic test previously described.
Patients with low back pain are commonly observed to have difficulty in adopting a mid or neutral position of the lumbar spine.
Twenty subjects with low back pain were required to reproduce an upright neutral posture of the lumbar spine following movement into flexion in a sitting position. Trunk positioning accuracy was measured with an electromagnetic tracking device.
The mean absolute value of the repositioning error in the sagittal plane was 2.25 degrees +/-0.88 degrees on day 1 and 2.32 degrees +/-1.62 degrees on day 2. The performance of patients with low back pain was similar to that of asymptomatic patients in a previous study, although subjects with low back pain overshot the neutral position more frequently (79%) than did nonimpaired subjects (50%).
Subjects with low back pain may have attempted to use extra mechanoreceptive cues to compensate for some kinesthetic deficit. Nevertheless, the kinesthetic test used was not sensitive enough to detect any repositioning deficits, and reasons for this are explored.
Lumbar segmental instability is considered to represent a significant sub-group within the chronic low back pain population. This condition has a unique clinical presentation that displays its symptoms and movement dysfunction within the neutral zone of the motion segment. The loosening of the motion segment secondary to injury and associated dysfunction of the local muscle system renders it biomechanically vulnerable in the neutral zone. The clinical diagnosis of this chronic low back pain condition is based on the report of pain and the observation of movement dysfunction within the neutral zone and the associated finding of excessive intervertebral motion at the symptomatic level. Four different clinical patterns are described based on the directional nature of the injury and the manifestation of the patient's symptoms and motor dysfunction. A specific stabilizing exercise intervention based on a motor learning model is proposed and evidence for the efficacy of the approach provided.
A prospective randomized controlled trial of exercise therapy in patients who underwent microdiscectomy for prolapsed lumbar intervertebral disc. Results of a pilot study are presented.
To determine the effects of a postoperative exercise program on pain, disability, psychological status, and spinal function.
Microdiscectomy is often used successfully to treat prolapsed lumbar intervertebral disc. However, some patients do not have a good outcome and many continue to have low back pain. The reasons for this are unclear but impairment of back muscle function due to months of inactivity before surgery may be a contributing factor. A postoperative exercise program may improve outcome in such patients.
Twenty patients who underwent lumbar microdiscectomy were randomized into EXERCISE and CONTROL groups. After surgery, all patients received normal postoperative care that included advice from a physiotherapist about exercise and a return to normal activities. Six weeks after surgery, patients in the EXERCISE group undertook a 4-week exercise program that concentrated on improving strength and endurance of the back and abdominal muscles and mobility of the spine and hips. Assessments of spinal function were performed in all patients during the week before surgery and at 6, 10, 26, and 52 weeks after. The assessment included measures of posture, hip and lumbar mobility, back muscle endurance capacity and electromyographic measures of back muscle fatigue. On each occasion, patients completed questionnaires inquiring about pain, disability and psychological status.
Surgery improved pain, disability, back muscle endurance capacity and hip and lumbar mobility in both groups of patients. After the exercise program, the EXERCISE group showed further improvements in these measures and also in electromyographic measures of back muscle fatigability. All these improvements were maintained 12 months after surgery. The only further improvement showed by the CONTROL group between 6 and 52 weeks was an increase in back muscle endurance capacity.
A 4-week postoperative exercise program can improve pain, disability, and spinal function inpatients who undergo microdiscectomy. [Key words: electromyogram median frequency, exercise therapy, intervertebral disc prolapse, microdiscectomy, randomized controlled trial, spinal function.
A cross-sectional observational design study was conducted to determine lumbar repositioning error in 15 subjects who had chronic low back pain with a clinical diagnosis of lumbar segmental instability and 15 asymptomatic participants.
To determine whether individuals with lumbar segmental instability have a decreased ability to reposition their lumbar spine into a neutral spinal position.
Proprioception of the lumbar spine has been investigated in individuals who have low back pain with variable results. The testing procedure's lack of sensitivity and the nonhomogeneity of groups may be responsible for the conflicting findings.
Repositioning accuracy of the lumbar spine was assessed using the 3Space Fastrak to determine error in 15 participants with lumbar segmental instability and 15 asymptomatic subjects. The participants were assisted into a neutral spinal sitting posture and then asked to reproduce this position independently over five trials separated by periods of relaxed full lumbar flexion.
Lumbosacral repositioning error was significantly greater in participants with lumbar segmental instability than in the asymptomatic group (t[28] = 2.48; P = 0.02. There also was a significant difference between the groups at each individual sensor.
The results of this study indicate that individuals with a clinical diagnosis of lumbar segmental instability demonstrate an inability to reposition the lumbar spine accurately into a neutral spinal posture while seated. This finding provides evidence of a deficiency in lumbar proprioceptive awareness among this population.
Many authors report changes in the control of the trunk muscles in people with low back pain (LBP). Although there is considerable disagreement regarding the nature of these changes, we have consistently found differential effects on the deep intrinsic and superficial muscles of the lumbopelvic region. Two issues require consideration; first, the potential mechanisms for these changes in control, and secondly, the effect or outcome of changes in control for lumbopelvic function. Recent data indicate that experimentally induced pain may replicate some of the changes identified in people with LBP. While this does not exclude the possibility that changes in control of the trunk muscles may lead to pain, it does argue that, at least in some cases, pain may cause the changes in control. There are many possible mechanisms, including changes in excitability in the motor pathway, changes in the sensory system, and factors associated with the attention demanding, stressful and fearful aspects of pain. A new hypothesis is presented regarding the outcome from differential effects of pain on the elements of the motor system. Taken together these data argue for strategies of prevention and rehabilitation of LBP.
The most common cause of low-back pain related to seating is posterior protrusion or extrusion of lower lumbar intervertebral discs.
The normal curve of the lumbar spine in adult man is determined by maintenance of the trunk-thigh and the knee angles at approximately 135 degrees.
Alteration of this normal lumbar curve, either an increase in standing erect or a decrease in sitting or stooping, is caused largely by the limited length and consequent pull of the trunk-thigh muscles of the opposite side.
The most important postural factor in the causation of low-back pain in sitting is decrease of the trunk-thigh angle and consequent flattening of the lumbar curve.
The next most important cause of low-back pain in sitting is lack of primary back support over the vulnerable lower lumbar intervertebral discs.
Added factors of comfort in seating are the shortness of the seat, a rounded narrow front border, an open space beneath for better positioning of the legs, and permissive change of position in the seat.
The design of all seats, regardless of model or size, should be based on this knowledge.
Psychosocial factors are known to act as obstacles to recovery from low back pain, but predictors of longer-term outcomes are not established. An average 4-year follow-up of a cohort of 252 low back pain patients attending for manipulative care was conducted to describe the longer-term course of low back pain, and to identify predictors of outcomes. Clinical and psychosocial data were obtained at baseline. Mailed questionnaires collected self-reported outcomes (pain, disability, recurrence and care seeking). Among the 60% who responded, the statistically significant reduction in mean Roland Disability Questionnaire score seen at 1 year did not improve further during follow-up. At the 4-year point, 49% of respondents reported residual disability, and 59% reported at least 'mild' pain. Symptom recurrence beyond the 1-year point was reported by 78% of respondents, with half of them seeking further care. Recurrence and care seeking were related to fear avoidance beliefs and duration of presenting symptoms. The disability score at 4-years was statistically significantly related to baseline depressive symptoms and higher pain intensity. Low back pain presenting for manipulative care is characterized by high levels of recurrence and care seeking over at least 4-years for many patients. Because psychosocial factors at presentation exert a long-term influence, they need to be considered by manual therapists.
Concepts of diagnosis and classification have a long history in medicine, while formal schemes of diagnostic classification in physical therapy are relatively new. Basic differences exist between medicine and physical therapy in the phenomena which are diagnosed and classified. However, similarities in the diagnostic and classification process provide an opportunity to learn from medicine as the process now evolves in physical therapy. This paper provides a brief history of the development of the concept of diagnostic classification in medicine and physical therapy. Difficulties associated with the process are described. Knowledge of these difficulties is used to analyze some of the evolving concepts of diagnostic classification in physical therapy, especially those related to orthopaedic physical therapy practice.
The study reported here aims to identify the extent of back pain experienced by 11-14 year old schoolchildren, and establish the intensity, duration and frequency of exposure to physical risk factors present in schools. This paper considers the sitting postures of schoolchildren in the classroom. The sitting postures of 66 children were recorded in normal lessons using the Portable Ergonomic Observation Method (PEO). The study found significant associations between flexed postures and low back pain. Static postures and neck and upper back pain were also associated. This study has implications for schools, designers and people in the field of work related musculoskeletal disorders. Further research is required to examine the association between sitting posture and pain reported at different spinal locations.
A systematic biomechanical analysis involving an artificial perturbation applied to individual lumbar muscles in order to assess their potential stabilizing role.
To identify which torso muscles stabilize the spine during different loading conditions and to identify possible mechanisms of function. SUMMARY OF BACKGROUND DATA.: Stabilization exercises are thought to train muscle patterns that ensure spine stability; however, little quantification and no consensus exists as to which muscles contribute to stability.
Spine kinematics, external forces, and 14 channels of torso electromyography were recorded for seven stabilization exercises in order to capture the individual motor control strategies adopted by different people. Data were input into a detailed model of the lumbar spine to quantify spine joint forces and stability. The EMG signal for a particular muscle was replaced either unilaterally or bilaterally by a sinusoid, and the resultant change in the stability index was quantified.
A direction-dependent-stabilizing role was noticed in the larger, multisegmental muscles, whereas a specific subtle efficiency to generate stability was observed for the smaller, intersegmental spinal muscles.
No single muscle dominated in the enhancement of spine stability, and their individual roles were continuously changing across tasks. Clinically, if the goal is to train for stability, enhancing motor patterns that incorporate many muscles rather than targeting just a few is justifiable.
The aim of this pilot study was to examine whether differences existed in spinal kinematics and trunk muscle activity in cyclists with and without non-specific chronic low back pain (NSCLBP). Cyclists are known to be vulnerable to low back pain (LBP) however, the aetiology of this problem has not been adequately researched. Causative factors are thought to be prolonged forward flexion, flexion-relaxation or overactivation of the erector spinae, mechanical creep and generation of high mechanical loads while being in a flexed and rotated position. Nine asymptomatic cyclists and nine cyclists with NSCLBP with a flexion pattern disorder primarily related to cycling were tested. Spinal kinematics were measured by an electromagnetic tracking system and EMG was recorded bilaterally from selected trunk muscles. Data were collected every five minutes until back pain occurred or general discomfort prevented further cycling. Cyclists in the pain group showed a trend towards increased lower lumbar flexion and rotation with an associated loss of co-contraction of the lower lumbar multifidus. This muscle is known to be a key stabiliser of the lumbar spine. The findings suggest altered motor control and kinematics of the lower lumbar spine are associated with the development of LBP in cyclists.
The importance of classifying chronic low back pain (LBP) patients into homogeneous sub-groups has recently been emphasized. This paper reports on two studies examining clinicians ability to agree independently on patients' chronic LBP classification, using a novel classification system (CS) proposed by O'Sullivan. In the first study, a sub-group of 35 patients with non-specific chronic LBP were independently classified by two 'expert' clinicians. Almost perfect agreement (kappa-coefficient 0.96; %-of-agreement 97%) was demonstrated. In the second study, 13 clinicians from Australia and Norway were given 25 cases (patients' subjective information and videotaped functional tests) to classify. Kappa-coefficients (mean 0.61, range 0.47-0.80) and %-of-agreement (mean 70%, range 60-84%) indicated substantial reliability. Increased familiarity with the CS improved reliability. These studies demonstrate the reliability of this multi-dimensional mechanism-based CS and provide essential evidence in a multi-step validation process. A fully validated CS will have significant research and clinical application.
This preliminary cross-sectional study was undertaken to determine if there were measurable relationships between posture, back muscle endurance and low back pain (LBP) in industrial workers with a reported history of flexion strain injury and flexion pain provocation. Clinical reports state that subjects with flexion pain disorders of the lumbar spine commonly adopt passive flexed postures such as slump sitting and present with associated dysfunction of the spinal postural stabilising musculature. However, to date there is little empirical evidence to support that patients with back pain, posture their spines differently than pain-free subjects. Subjects included 21 healthy industrial workers and 24 industrial workers with flexion-provoked LBP. Lifestyle information, lumbo-pelvic posture in sitting, standing and lifting, and back muscle endurance were measured. LBP subjects had significantly reduced back muscle endurance (P < 0.01). LBP subjects sat with less hip flexion, (P = 0.05), suggesting increased posterior pelvic tilt in sitting. LBP subjects postured their spines significantly closer to their end of range lumbar flexion in 'usual' sitting than the healthy controls (P < 0.05). Correlations between increased time spent sitting, physical inactivity and poorer back muscle endurance were also identified. There were no significant differences found between the groups for the standing and lifting posture measures. These preliminary results support that a relationship may exist between flexed spinal postures, reduced back muscle endurance, physical inactivity and LBP in subjects with a history of flexion injury and pain.
Low back pain is a major burden to society. Many people will experience an episode of low back pain during their life. Some people develop chronic low back pain, which can be very disabling. Low back pain is associated with high direct and indirect costs. Recent epidemiological data suggest that there is a need to revise our views regarding the course of low back pain. Low back pain is not simply either acute or chronic but fluctuates over time with frequent recurrences or exacerbations. Also, low back pain may frequently be part of a widespread pain problem instead of being isolated, regional pain. Although epidemiological studies have identified many individual, psychosocial and occupational risk factors for the onset of low back pain, their independent prognostic value is usually low. Similarly, a number of factors have now been identified that may increase the risk of chronic disability but no single factor seems to have a strong impact. Consequently, it is still unclear what the most efficient strategy is for primary and secondary prevention. In general, multi-modal preventative approaches seem better able to reflect the clinical reality than single-modal interventions.
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