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Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control impairments as underlying mechanism

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Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control impairments as underlying mechanism

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Abstract

Low back pain (LBP) is a very common but largely self-limiting condition. The problem arises however, when LBP disorders do not resolve beyond normal expected tissue healing time and become chronic. Eighty five percent of chronic low back pain (CLBP) disorders have no known diagnosis leading to a classification of 'non-specific CLBP' that leaves a diagnostic and management vacuum. Even when a specific radiological diagnosis is reached the underlying pain mechanism cannot always be assumed. It is now widely accepted that CLBP disorders are multi-factorial in nature. However the presence and dominance of the patho-anatomical, physical, neuro-physiological, psychological and social factors that can influence the disorder is different for each individual. Classification of CLBP pain disorders into sub-groups, based on the mechanism underlying the disorder, is considered critical to ensure appropriate management. It is proposed that three broad sub-groups of CLBP disorders exist. The first group of disorders present where underlying pathological processes drive the pain, and the patients' motor responses in the disorder are adaptive. A second group of disorders present where psychological and/or social factors represent the primary mechanism underlying the disorder that centrally drives pain, and where the patient's coping and motor control strategies are mal-adaptive in nature. Finally it is proposed that there is a large group of CLBP disorders where patients present with either movement impairments (characterized by pain avoidance behaviour) or control impairments (characterized by pain provocation behaviour). These pain disorders are predominantly mechanically induced and patients typically present with mal-adaptive primary physical and secondary cognitive compensations for their disorders that become a mechanism for ongoing pain. These subjects present either with an excess or deficit in spinal stability, which underlies their pain disorder. For this group, physiotherapy interventions that are specifically directed and classification based, have the potential to impact on both the physical and cognitive drivers of pain leading to resolution of the disorder. Two case studies highlight the different mechanisms involved in patients with movement and control impairment disorder outlining distinct treatment approaches involved for management. Although growing evidence exists to support this approach, further research is required to fully validate it.

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... 28,29 For example LBP that is localized, mechanically provoked and linked to maladaptive functional and lifestyle behaviours, resulting in abnormal tissue loading, may be associated with nociceptive and infl ammatory pain features such as localized heat and pressure hyperalgesia. 30,31 In contrast, 'insidious' pain fl ares or PLBP linked to other pain and health co-morbidities and high levels of psychosocial and lifestyle stresses, is often widespread and non-mechanical in nature. This may present with either an absence of clinical signs or be associated with exaggerated pain responses to minor mechanical triggers with localized allodynia and/or widespread cold hyperalgesia. ...
... This may present with either an absence of clinical signs or be associated with exaggerated pain responses to minor mechanical triggers with localized allodynia and/or widespread cold hyperalgesia. 30,32,33 While for some their pain characteristics appear clearly defi ned, LBP for many presents as a mixed picture refl ecting a combination of both peripheral and central pain mechanisms (see Fig. 45-1 ). 6 PLBP has also been associated with brain changes such as a loss of grey matter, increased resting brain state, changes in the sensorimotor cortex (i.e. ...
... 17 Growing evidence suggests that these behaviours are often maladaptive and provocative in PLBP. 17,30 This is like a 'limp' for a sprained ankle that may be adaptive in the acute phase of a traumatic injury; however, when it persists past natural tissue healing time it becomes maladaptive and provocative. These behaviours are commonly associated with high levels of trunk muscle co-contraction (excessive 'stability'), are not stereotypical 17,30 and are linked with proprioceptive deficits 54,55 and altered body schema. ...
... 1,2 This could be because mechanical LBP has different underlying impairments. [2][3][4][5][6] Clinical lumbar instability has been identified as a subgroup of LBP. 7,8 This subgroup demonstrates impaired lumbopelvic control (iLPC) represented by observed aberrant movement patterns during functional movements. ...
... 7,8 This subgroup demonstrates impaired lumbopelvic control (iLPC) represented by observed aberrant movement patterns during functional movements. [7][8][9] These repeated aberrant movements result in excessive tissue stress and microtrauma which could further cause episodes of LBP. 5 Furthermore, evidence indicates the existence of these aberrant movements in individuals with both a history of LBP and chronic LBP, 4,[9][10][11] indicating that iLPC may be responsible for recurrent LBP (rLBP). 4,[9][10][11] One possible cause that could be responsible for such iLPC is arthrogenic muscle inhibition of the lumbar multifidus muscles (LM). ...
... [7][8][9] These repeated aberrant movements result in excessive tissue stress and microtrauma which could further cause episodes of LBP. 5 Furthermore, evidence indicates the existence of these aberrant movements in individuals with both a history of LBP and chronic LBP, 4,[9][10][11] indicating that iLPC may be responsible for recurrent LBP (rLBP). 4,[9][10][11] One possible cause that could be responsible for such iLPC is arthrogenic muscle inhibition of the lumbar multifidus muscles (LM). 12,13 This reflex inhibition may reduce the ability of LM to generate sufficient force to stabilize the lumbar spine; thereby, increasing the shear forces on the lumbar spine resulting in tissue stress and microtrauma. ...
Article
Objective: To determine lumbar multifidus muscle (LM) activation deficits in individuals with impaired lumbopelvic control (iLPC) based on musculoskeletal ultrasound (MSKUS) in conjunction with electrical stimulation approach, and the correlation between back extension force and LM activation. Design: A cross-sectional study design. Setting: A university laboratory. Participants: Fifty participants (25 iLPC and 25 NoLBP) were recruited from the university physical therapy clinic and surrounding areas. Main Outcome Measures: The MSKUS was used to measure LM thickness at rest, maximum voluntary isometric contraction (MVIC), and electrical stimulation combined with MVIC, while a hand-held dynamometer was used to record force during MVIC and electrical stimulation combined with MVIC. These data were used to derive LM activation (LMACT) and percentage force generation (ForceGEN). Results: The iLPC group had significantly lower LMACT (17%) than the NoLBP group (P<0.05). No significant difference was seen in ForceGEN between the NoLBP and iLPC groups (P>0.05). No significant correlation was seen between LMACT and ForceGEN (P>0.05). Conclusion: The findings support the utility of our protocol to determine LM activation deficits. The lower LM activation in iLPC group suggests that individuals with iLPC were unable to fully recruit the motor units available in LM. Force generation measurements may not be an appropriate approach to determine such deficits in LM.
... Although improvements for guidelines of CLBP clinical practice have been achieved over the years [4], the effectiveness of therapies, including rehabilitation, remains modest at best [5,6]. Variations in treatment outcomes could be driven by the heterogeneity of the CLBP population [7][8][9][10][11]. In CLBP, central and peripheral nociceptive processes are influenced by multidimensional factors [12][13][14]. ...
... Three studies examined 3D kinematic trunk patterns during repeated trunk flexionextension tasks in patients with CLBP with low pain intensity (VAS < 2) and controls (Table S1) [34][35][36]. Patients exhibited higher local trunk stability than controls over multiple cycles (4)(5)(6)(7)(8)(9)(10), as quantified by a lower maximal Lyapunov exponent (λmax; p = 0.03) for patients with CLBP than controls. The λmax describes the capability to resist local perturbations [37], with lower values implying higher local stability of trunk movements [34]. ...
... The substantial between-subject variance in motor variability in CLBP could also be driven by the heterogeneity of the CLBP population phenotyping [7][8][9][10][11]. Biopsychosocial models suggest that the fear of pain keeps a tight rein on motor behavior in patients with CLBP [67]. ...
Article
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The identification of homogeneous subgroups of patients with chronic low back pain (CLBP), based on distinct patterns of motor control, could support the tailoring of therapy and improve the effectiveness of rehabilitation. The purpose of this review was (1) to assess if there are differences in motor variability between patients with CLBP and pain-free controls, as well as inter-individually among patients with CLBP, during the performance of functional tasks; and (2) to examine the relationship between motor variability and CLBP across time. A literature search was conducted on the electronic databases Pubmed, EMBASE, and Web of Science, including papers published any time up to September 2021. Two reviewers independently screened the search results, assessed the risk of bias, and extracted the data. Twenty-two cross-sectional and three longitudinal studies investigating motor variability during functional tasks were examined. There are differences in motor variability between patients with CLBP and pain-free controls during the performance of functional tasks, albeit with discrepant results between tasks and among studies. The longitudinal studies revealed the persistence of motor control changes following interventions, but the relationship between changes in motor variability and reduction in pain intensity was inconclusive. Based on the reviewed literature, no stratification of homogeneous subgroups into distinct patterns of motor variability in the CLBP population could be made. Studies diverged in methodologies and theoretical frameworks and in metrics used to assess and interpret motor variability. In the future, more large-sample studies, including longitudinal designs, are needed, with standardized metrics that quantify motor variability to fill the identified evidence gaps.
... [33][34][35] Consequently, this results in different management of NSLBP patients from different cultural backgrounds. Overall, only four papers describing classification systems with a biopsychosocial approach could be identified, [36][37][38][39] the others used a solely biomechanical or psychosocial approach. The majority of the classification systems found are based on a biomedical approach and come from a wide variety of therapeutic schools, methods, and health professionals. ...
... Even if the biomechanical approach dominates, all classification strategies acknowledge psychological and psychosocial influencing factors, such as cognitive or behavioural aspects in the OCS. 39 Nevertheless, they diverge essentially in their emphasis on psychosocial factors. 40 Despite this, detailed examination procedures of back and movement function have not yet found their way into the guidelines for non-specific LBP. ...
... Various studies have shown that complex musculoskeletal dysfunctions play a role in chronic LBP. 39,[60][61][62][63] Both, the ambiguous denotation and the lack of a complete biomedical approach have led to numerous attempts to identify subgroups. But in spite of this, it has not been possible to describe any uniform subgroups so far. ...
Article
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This article aims to provide new perspectives for the treatment of low back pain (LBP). A narrative literature review highlights the treatment strategies currently anchored in the guidelines as well as the extensive attempts to identify subgroups within the non-specific low back pain (NSLBP) classification. A variety of multimodal approaches exist for both diagnostic assessments and therapy approaches. Nonetheless, there are often gaps in the classification systems as well as in published treatment concepts with regard to the implementation of musculoskeletal functional disorders. Indeed, a growing body of evidence shows that more holistic and flexible approaches are needed to individually diagnose and target the complexity of LBP. As an example, both a diagnostic and a (independently developed) therapeutic LBP concept will be presented and discussed. Ultimately, guidelines and subgroup classification systems can only reflect the complexity of LBP, if they capture its entire multidimensional and biopsychosocial character in both the diagnostic and therapeutic processes. Furthermore, the expansion of the pain definition to include the nociplastic pain mechanism, as an important driver of LBP, has the potential to provide important impulses for further necessary research. In conclusion, the implementation of a functional musculoskeletal approach along with the emerging nociceptive pain concept in individually targeted holistic approaches seems to be the successful way to deal with the complexity of LBP.
... Although several studies have demonstrated effective outcomes of physical therapy interventions, the recurrence rates are still high [1]. Such high recurrence rates could have resulted from the fact that we treated patients with LBP as a homogeneous group [2][3][4]. Current research evidence suggests that subgrouping LBP patients is necessary to provide a more specific intervention more effectively addressing the patients' problems [2][3][4]. ...
... Such high recurrence rates could have resulted from the fact that we treated patients with LBP as a homogeneous group [2][3][4]. Current research evidence suggests that subgrouping LBP patients is necessary to provide a more specific intervention more effectively addressing the patients' problems [2][3][4]. ...
... Exercise prescriptions for CLBP have also been designed to address movement control impairments (MCI) (Dankaerts & O'Sullivan, 2011;O'Sullivan, 2005 (Lomond et al., 2015;Saner et al., 2015;Saner et al., 2016). Recently, a series of studies were published reporting short and long-term results of an exercise prescription based on MCI compared to a general exercise program (Saner et al., 2015;Saner et al., 2016). ...
... Recently, a series of studies were published reporting short and long-term results of an exercise prescription based on MCI compared to a general exercise program (Saner et al., 2015;Saner et al., 2016). In these studies, O'Sullivan's classification system for MCI (O'Sullivan, 2005) was used to sub-categorise patients and develop the exercise prescription. The general exercise group for this research was an exercise program focusing on the core musculature, without any individualisation (Saner et al., 2015). ...
Thesis
Full-text available
Chronic low back pain carries a large global burden of disease. Currently, exercise is recognised as a key treatment for chronic low back pain. However, management of chronic low back pain presents exercise-based practitioners with numerous, confusing, and conflicting treatment options. Broadly, these options can be classified under biomedical or biopsychosocial treatment paradigms. An overarching problem within chronic low back pain literature is the understanding of if practitioners are applying best practice approaches, and if not, how this can be improved. Based on these evident gaps in our understanding of the management of chronic low back pain, this thesis investigated the following: How do exercise-based practitioners currently manage chronic low back pain, and what attitudes and beliefs underpin this management? What does a pragmatic biopsychosocial exercise-based approach to chronic low back pain look like, and what role does exercise play in this intervention? Can education targeted at current gaps in practice by exercise-based practitioners, combined with pragmatic understanding of biopsychosocial exercise prescription, improve clinical decision making? This thesis examined chronic low back pain at the level of the patient and of the practitioner. This thesis found exercise not to be a significant factor in the design of combined exercise and education interventions for chronic low back pain. This finding allows practitioners to move away from systemised approaches to exercise for chronic low back pain and explore prescriptions optimal for the individual patient, rather than optimal for back pain in general. However, this thesis also found practitioners with biomedical beliefs, even when concomitant with biopsychosocial beliefs, are less likely to apply these contemporary approaches. Indeed, targeted education does improve clinical decision-making through a reduction in biomedical beliefs, which increases the care provided to patients. This improvement in clinical decision-making through a reduction in biomedical beliefs, and no change to biopsychosocial, may suggest the relative importance of biomedical beliefs on approaches to chronic low back pain.
... Individuals who chronically suffer pain conditions also tend to be prone to altered pain perception and psychological comorbidities [8,9]. Particularly chronic LBP is not attributable to a known diagnosis in 85% of the patients, and therefore classified "non-specific" (cnLBP) [10]. However, while successful treatment remains challenging, a consensus exists on a biopsychosocial approach in LBP management, leading to respective guidelines recommending, amongst others, behavioral therapy as well as awareness-enhancing interventions [11][12][13][14]. ...
... Central pain is reckoned to cause or influence maladaptive movement strategies [10,60] that will be assessed by MCD. This battery of six standardized tests showed acceptable reliability of detecting movement/motor control problems of the lower back [61]. ...
Article
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Background . Low back pain (LBP) is among the most common physical ailments and its chronic manifestation is a leading cause for disability worldwide. LBP is not attributable to a known diagnosis in 85% of the cases and therefore called chronic non-specific LBP (cnLBP). Passive immersion in warm water is commonly claimed to reduce muscular tension and pain, but not yet sufficiently investigated with regard to cnLBP. The current study compares three passive aquatic interventions regarding their effects on cnLBP: floating (resting in a supine immersed position on flotation devices), WATSU (a passive hands-on treatment, in which a practitioner stands in warm water, gently moving and massaging the client), and a Spa session. Methods . In this randomized cross-over clinical trial, all 24 adult participants with cnLBP will undergo the three interventions in balanced order with a washout-period of at least two weeks in between. Assessments will take place at baseline and follow-up of study and immediately before and after each intervention. Assessments cover the primary outcome self-reported current pain (Visual Analog Scale, range: 0–100 mm), other self-report questionnaires (addressing, e.g., personality traits or -states), and physiological parameters (e.g., measurement of spinal range of motion). Discussion . The study adds estimates of intervention-specific effect-sizes of widespread passive aquatic interventions to cnLBP. The study also points to potential underlying pain-reducing mechanisms. Trial registration . The protocol was approved by the Ethics Committee of the Canton Bern (ProjectID: 2018–00461). Trial registration is intended at ClinicalTrials.gov.
... The increasing prevalence of low back pain (LBP) is extensively detailed in the literature [2,3], which shows the necessity of a better understanding of the acute stage of the pathology to improve diagnosis and treatment, as well as to minimize the socio-economic burden [4]. Researchers categorize about 85% of LBP as non-specific, without structural changes, inflammation, or specific underlying disease [5,6]. Nevertheless, LBP has been associated with changes in neuromuscular activity [7,8], decreased spinal mobility, limited lumbar muscle flexibility, and altered spinal kinematics [9]. ...
Article
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This research aimed to identify changes in muscle mechanical properties (MMPs) when a standardized sequence of movements is performed and to determine the influence of acute low back pain (LBP) and age on the MMPs. Socio-demographic, clinical variables and MMPs were collected in 33 patients with LBP and 33 healthy controls. A 2 × 2 × 2 (group × age × time) analysis of variance (ANOVA) mixed model was used to determine the effect of the study factors on the different MMPs. There were no significant triple interactions. After the movements, tone and stiffness increased 0.37 Hz and 22.75 N/m, respectively, in subjects <35 years, independent of their clinical status. Relaxation showed differences by age in healthy subjects and creep in LBP subjects. Furthermore, elasticity was higher in <35 years (p < 0.001) without the influence of any other factor. In conclusion, sequenced movements can modify tone and stiffness as a function of age, while age-associated changes in viscoelastic characteristics depends on pain but not on movements. The MMPs should be assessed, not only at the beginning of the physical examination at rest, but also along the patient’s follow-up, depending on their pain and age, in a clinical setting.
... Low back pain (LBP) is the most common musculoskeletal disorder, affects people of all ages, places a major burden on global health and has a high economic cost [1,2]. Eighty-five percent of all cases of LBP are non-specific, which is defined as LBP not attributable to a recognisable, known specific pathology [3]. Recurrence and chronicity are common, with > 60% of patients still experiencing pain 1 year after an acute LBP episode, and lifetime prevalence of chronic LBP (CLBP) of approximately 23% [1,4]. ...
Article
Objective Aquatic exercise therapy is used for the treatment and management of chronic low back pain (CLBP). However, to the authors’ knowledge, no studies to date have compared muscle activity between different aquatic exercises performed by people with CLBP. As such, this study assessed and compared muscle activity, pain, perceived exertion and exercise intensity between different rehabilitative aquatic exercises. Design Cross-sectional. Setting A 25-m indoor swimming pool within a university building. Participants Twenty participants with non-specific CLBP. Assessment Twenty-six aquatic exercises in shallow water (1.25-m depth). Muscle activity was quantified bilaterally for the erector spinae, multifidus, gluteus maximus and medius, rectus abdominis, and external and internal obliques. Main outcomes Mean and peak muscle activity, pain (visual analogue scale), perceived exertion (Borg scale) and exercise intensity (heart rate). Results Hip abduction/adduction and extension/flexion exercises produced higher activity for gluteal muscles. Variations of squat exercises increased the activity of back extensors. Higher abdominal muscle activity was produced with exercises that made use of buoyancy equipment and included leg and trunk movements while floating on the back, and with some proprioceptive and dynamic lower limb exercises. Pain occurrence and intensity were very low, with 17 exercises being pain free. Conclusions This study provides evidence on trunk and gluteal muscle activity, pain, intensity and perceived exertion for people with CLBP performing aquatic exercises. The findings may be useful when prescribing exercises for rehabilitation, as physiotherapists seek to implement progression in effort and muscle activity, variation in exercise type, and may wish to target or avoid particular muscles.
... According to studies conducted in line with "uses and gratifications approach" (Katz et al., 1973), there are a large number of motives underlying the use of social media. People utilize social media platforms for communication and social interaction (Cheng et al., 2014;Kim et al., 2011;Lee et al., 2015;Yenilmez Kacar, 2021) either through interpersonal or "masspersonal" communication applications (O'Sullivan, 2005), information seeking (Boztepe Taskiran, 2019; Leung, 2013;Throuvala et al., 2019), information dissemination (Johnson & Yang, 2009;Smock et al., 2011), entertainment (Cheng et al., 2014;Leung, 2013), relaxation (Gadekar & Krishnatray, 2017;Smock et al., 2011), surveillance (Cheng et al., 2014;Malik et al., 2015) and affection seeking purposes (Apodaca, 2017;Sung et al., 2016), etc. Given the social isolation and forced home confinement during the pandemic, social media channels were the only means for people to stay in touch with their social circles, to engage in business, educational practices and hobbies, to get latest news and to pursue interests. ...
Conference Paper
Because of COVID-19 pandemic, the world went through long periods of social distancing and lockdowns as a precaution against the spread of the virus. During this period, there was a significant increase in the use of social media since more time was spent at home and social media were the sole means of social interaction and communication. Based on the fact that social media function as an alternative socialization setting to face-to-face communication, we hypothesized that the use of social media during the pandemic had a positive impact on mental health of individuals especially by alleviating the feeling of loneliness. Accordingly, the current study aims to explore the relationship between the usage of social media and loneliness during the pandemic and to propose a model to explain this particular association. To this end, a pilot study was conducted with an online survey on 178 participants on 18-31 May, 2021, in Turkey. Relevant statistical analyses were implemented on SPSS 22.0 to detect correlations among demographic variables, scores on UCLA loneliness scale and data on the use of social media. Consistent with the hypothesis, the results revealed a negative correlation between the use of social media (time spent on social media; number of followers; number of accounts) and loneliness. In conclusion, the study demonstrates that social media can be utilized as a beneficial social interaction platform to mitigate the feeling of loneliness caused by stay-at home orders during the pandemic.
... Physical rehabilitation aims to restore the function of specific muscles and improve the postural performance by stimulating, via proper motor exercises, the appropriate integration and managing in all the central nervous system components controlled posture, with a focus on trunk and spine [16,82]. NSLBP is multifactorial [83,84], and no single exercise programme is optimal for all NSLBP patients [85]. However, MCE effectiveness compared to other approaches is debated [16,23,24]. ...
Article
Full-text available
The literature shows that low back pain causes a reduced lumbar range of movement, affecting patients′ proprioception and motor control. Nevertheless, studies have found that proprioception and motor control of the spine and posture are vague and individually expressed even in healthy young adults. This study aimed to investigate the standing posture and its modifications induced by an instinctive self-correction manoeuvre in subacute and chronic nonspecific low back pain (NSLBP) patients to clarify how NSLBP relates to body upright posture, proprioception, and motor control and how these are modified in patients compared to healthy young adults (121 healthy young adults: 57 females and 64 males). A cohort of 83 NSLBP patients (43 females, 40 males) were recruited in a cross-sectional observational study. Patients′ entire body posture, including 3D spine shape reconstruction, was measured using a non-ionising 3D optoelectronic stereophotogrammetric approach. Thirteen quantitative biomechanical parameters describing the nature of body posture were computed. The statistical analysis was performed using multivariate methods. NSLBP patients did not present an altered proprioception and motor control ability compared to healthy young adults. Furthermore, as for healthy subjects, NSLBP patients could not focus and control their posture globally. Proprioception and motor control in natural erect standing are vague for most people regardless of gender and concurrent nonspecific low back pain. Self-correction manoeuvres improving body posture and spine shape must be learned with specific postural training focusing on the lumbar spine.
... The understanding of chronic low back pain (CLBP), a frequent causes of disability worldwide, remains limited [1]. While alterations in spinal movement have been suggested as one of the key physical factors in CLBP [2,3], with differences frequently reported between individuals with and without CLBP [4,5], the role of spinal movement in CLBP persistence and recovery remains poorly understood. Clarifying this relationship will notably require longitudinal research, which raises the question of the reliability of movement measures in repeated study designs. ...
Article
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Background Longitudinal research is required to better understand the role of spinal movement alterations in chronic low back pain (CLBP). To this end, it is critical to assess the between-session reliability of spinal movement measures. Research question What is the within/between-session reliability of spinal movement measures in patients with CLBP and asymptomatic controls? Methods Spinal movement was recorded prospectively during two sessions, a week apart, for 20 patients with CLBP (60% male; 40.0 ± 12.3 years old) and 20 asymptomatic individuals (55% male; 38.2 ± 10.9 years old). Sagittal-plane angular amplitude and angular velocity at the lower lumbar, upper lumbar, lower thoracic and upper thoracic joints, as well as maximal erector spinae activity were measured during five daily-activity tasks. In addition, task-independent measures were obtained by averaging the measures across tasks. The Intraclass Correlation Coefficient (ICC 2,1) and the minimal detectable change (MDC) were calculated. Pearson correlation was used to compare task-independent and task-specific measures. Results Between-session ICCs in patients with CLBP were mostly moderate to good for maximal angular amplitude and erector spinae activity measures. Lower ICCs were observed for range of angular motion and angular velocity measures (42% of ICCs < 0.5). Median MDCs were 9.6°, 18.3°/s and 1.0% for angular amplitude, angular velocity and erector spinae activity measures, respectively. The reliability of task-independent and task-specific measures was strongly correlated (r = 0.91, p<0.001). Significance Sagittal-plane maximal angular amplitude and erector spinae activity measures during various daily-activity tasks demonstrated mostly moderate to good between-session ICCs. However, relatively large MDCs suggested that important changes are needed to be detectable. Task-independent measures reported similarly acceptable ICCs than task-specific measures, supporting their use to describe spinal movement.
... Such misconceptions among doctors have previously been found and may be due to the use of a biomedical approach to LBP. 5 Doctors are therefore more likely to advise patients with LBP to use caution when moving, lifting, and exercising to protect the spine, advice which is considered to have a negative effect on recovery as it can lead the patient into a vicious circle of fear and protective behavior. 1,5,8,14,[26][27][28][29][30] In contrast, reassurance and positive attitudes and beliefs towards LBP and movement has been shown to promote recovery. 31 The perceived vulnerability of the spine is a well-known risk factor for chronic LBP and should be countered by education that helps patients to understand that their spine is a strong structure, rather than advice to be cautious when bending the back. ...
Article
Background A common misconception about low back pain (LBP) is that the spine is weak and that lumbar flexion should be avoided. Because the beliefs of health-care professionals (HCPs) influence patients, it is important to understand the attitudes of health care professionals towards LBP and lifting. Objectives To assess and compare the perceptions of different categories of HCPs regarding the safety of specific movement strategies used to lift a light load, and their beliefs regarding back pain. The secondary aim was to determine whether certain factors influenced the beliefs of HCPs. Methods Data were collected via an electronic survey. Student and qualified physical therapists (PTs), medical students, and general practitioner (GP) trainees were included. The questionnaire included eight photographs, depicting eight different strategies to lift a light load. Respondents were requested to select the strategy(s) they considered as “unsafe” to use for asymptomatic people with a previous history of LBP and people with chronic LBP. Beliefs and attitudes towards LBP were evaluated using the Back Pain Attitudes Questionnaire (Back-PAQ). Results Questionnaires from 1005 participants were included. Seventy percent of qualified PTs considered none of the strategies as harmful (versus 32% of PT students, 9% of GP trainees and 1% of medical students). Qualified PTs had higher Back-PAQ scores (mean ± SD: 13.6 ± 5.5) than PT students (8.7 ± 5.7), GP trainees (5.9 ± 5.9) and medical students (4.1 ± 5.2), indicating less misconceptions regarding LBP. Having LBP negatively influenced beliefs while taking a pain education course positively influenced beliefs. Conclusion Misconceptions regarding LBP and the harmfulness of lifting a light load with a rounded back remain common among HCPs, particularly medical doctors.
... Therefore, in the first step it was decided to examine people with CLBP during SiToSt and StToSi activities in the 3 planes of motion. In addition, it should be considered that CLBP is a heterogeneous group of patients with LBP, which should be placed in more homogeneous subgroups (8,13,(18)(19)(20) and then compared with healthy people, which has been neglected so far in the previous studies (16,17). The recent studies have also revealed patients with CLBP are a group of heterogeneous patients with dissimilar movement behaviors (8,13,21). ...
Article
Background: To our knowledge, no study has examined the kinematics of lumbopelvic-hip complex of individuals with chronic low back pain (CLBP) who had lumbar flexion+rotation (F+R) syndrome during sit to stand (SiToSt) and stand to sit (StToSi) activities. Thus, this study aimed to examine movement patterns of the lumbopelvic-hip complex in participants with CLBP classified into F+R syndrome subgroup. Methods: This was a cross sectional study. A 3-dimensional motion capture system was used to record movements of the lumbar spine and hips during SiToSt and StToSi. Participants were 20 patients with LBP classified in lumbar F+R subgroup, based on the movement impairment system model, and 20 asymptomatic individuals. The study was approved by Shahid Beheshti University of Medical Sciences (IR, SBMU.RETECH, and REC.1395.365). Results: Greater and significant lumbar flexion, with SiToSt, and lumbar extension, with StToSi, were observed in the patients. In addition, the patients exhibited a greater magnitude of lumbar rotation during SiToSt. No significant difference was observed between the 2 groups in hip motions. Conclusion: The patients with lumbar F+R syndrome tend to move their lumbopelvic region to a greater extent in sagittal and horizontal planes during SiToSt and StToSi compared with participants without low back pain.
... Although the results showed that the motion angles of the lumbar spine and hip joints were not related to intensity of low back pain, they were related to disability caused by low back pain. However, it is reported that various factors, such as psychosocial and neurophysiological factors, are involved in the mechanism of low back pain in addition to mechanical load 22) . Therefore, it is difficult to interpret the intensity of low back pain solely based on kinematic factors. ...
Article
[Purpose] We aimed to examine the relationships among low back pain, lumbar-hip motion angle, and lumbar perceptual awareness in young adults to improve the treatment of low back pain. [Participants and Methods] Data were collected from 36 university students with low back pain. The items included for evaluation were the low back pain intensity (Numeric Rating Scale), disability due to low back pain (Oswestry Low Back Pain Disability Index), lumbar spine and hip motion angles in test movements, and perceptual awareness (Fremantle Back Awareness Questionnaire). The test movements employed included trunk forward bending, trunk back bending, and prone hip extension. The motion angles of the lumbar spine and hip joints were measured using a wearable sensor. [Results] The Numeric Rating Scale was not correlated with the lumbar hip motion angle and perceptual awareness. The Oswestry Low Back Pain Disability Index was correlated with lumbar hip motion angles, at the beginning of trunk forward bending and at maximum trunk backward bending, and with perceptual awareness. [Conclusion] There are relationships among disabilities due to low back pain, lumbar hip motion angles, and perceptual awareness in each test movement; however, they vary depending on the type and angle of the test movement conducted.
... Patients were recruited from the orthopaedic clinic of a local hospital and several local general practices. Patients were eligible for the study if they had a history of RLBP (repeated episodes of pain in past year collectively lasting for less than 6 mo) [24] of a nonspecific nature, defined as back pain complaints occurring without identifiable specific anatomical or neurophysiological causative factors [2]. To establish this, all patients included had a prior clinical examination by their physician, including a radiograph or a magnetic resonance imaging scan. ...
Article
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Background: Paraspinal muscle strength and fatigue are considered important in low back pain (LBP) prevention and rehabilitation. High reliability of paraspinal strength and electromyographic (EMG)-fatigue parameters has not been universally reported. Moreover, the discriminative validity of these parameters requires further exploration, under the threat of potentially poor reliability of the methods examined. Aim: To investigate the reliability and discriminative validity of paraspinal strength and EMG-related fatigue in subjects with recurrent LBP and healthy participants. Methods: Test-retest measurements were performed in 26 healthy and 66 LBP volunteers, for reliability. Paraspinal isometric maximal and mean strength were determined with a maximum voluntary isometric contraction (MVIC) protocol, performed in a custom-made device. For the fatigue test, participants performed a 60% MIVC level continuous isometric contraction of the paraspinals, in conjunction with EMG analysis from 4 muscle sites of the lumbar spine. Initial median frequency (IMF), the median frequency slope (MFslope), as well as the root mean square (RMS) slope EMG parameters were used as fatigue measures. Data were analysed with repeated measures ANOVA for test-retest differences. For reliability, the intraclass correlation coefficient (ICC3,1), standard error of the measurement (SEM) and the smallest detectable difference (SDD) were reported. Group-related differences for fatigue measures were analysed with a Multivariate Analysis of Covariance, with age, weight and strength as covariates. Results: Isometric strength presented statistically significant between-day differences (P < 0.01), however these did not exceed 10% (healthy: 7.2%/LBP-patients: 9.7%) and ICC reliability values were excellent, yet test-retest error was increased for the patient group (healthy: ICC3,1: 0.92-0.96, SEM: 5.72-5.94 Hz, SDD: 18.51%-18.57%/LBP-patients: ICC3,1: 0.91-0.96, SEM: 6.49-6.96, SDD: 30.75%-31.61%). For the frequency data, IMF reliability was excellent (healthy: ICC3,1: 0.91-0.94, SEM: 3.45-7.27 Hz, SDD: 9.56%-20.14%/patients: ICC3,1: 0.90-0.94, SEM: 6.41-7.59 Hz, SDD: 17.75%-21.02%) and of MF raw and normalised slopes was good (healthy: ICC3,1: 0.78-0.82, SEM: 4.93-6.02 Hz, SDD: 13.66-16.67%/LBP-patients: ICC3,1: 0.83-0.85, SEM: 6.75-7.47 Hz, SDD: 18.69%-20.69%). However, the reliability for RMS data presented unacceptably high SDD values and were not considered further. For discriminative validity, less MVIC and less steep MFslopes were registered for the patient group (P < 0.01). Conclusion: Reliability and discriminative ability of paraspinal strength and EMG-related frequency parameters were demonstrated in healthy participants and patients with LBP.
... 85% of low back pain(LBP) is non-specific low back pain (NS-LBP) without structural changes or inflammatory response in a specific region [1]. It is called non-specific because the cause of pain is not precisely identified despite the high prevalence [2], and most of the LBP treated by physical therapists in the clinic is NS-LBP [3]. ...
... We noted that the Lee et al 34 There is growing evidence of effectiveness of multimodal therapy for chronic musculoskeletal pain, as physical, psychosocial, and behavioral factors contribute toward the development of chronic pain. 44 Multimodal therapy aims at targeting all of these factors with a well-rounded holistic approach. 45 However, there is a lack of consensus on the types of therapeutic interventions, method of assessment, duration and frequency of sessions, and length of intervention. ...
Article
Background and Purpose: Chronic, noninflammatory musculoskeletal pain is common in the aged population and management can be challenging for older people due to multimorbidity, social isolation, and physical frailty. The aim of this scoping review is to summarize and discuss the evidence related to home-based health care interventions for the older population, with chronic, musculoskeletal pain. Methods: A review of the literature using 8 electronic databases (Embase, MEDLINE, CINAHL, PubMed, Cochrane Library, Physiotherapy Evidence Database [PEDro], Scopus, and Web of Science) was performed, following the PRISMA-ScR guidelines. English language published studies that assessed home-based health care intervention/s, in men and women 75 years and older, with chronic, noninflammatory musculoskeletal pain where included. Two authors independently reviewed the articles and extracted data into a preformulated chart. Results and Discussion: The database search identified 4722 studies of which 7 studies met the inclusion criteria. Six of the 7 studies were randomized controlled trials and 5 studies focused on a single-site pain. The type of home-based interventions in the included studies was physical therapy (n = 2), psychotherapy (n = 3), and multimodal therapy (combination of multiple therapies) (n = 2). Participation completion rate was more than 74% in 6 out of 7 studies. Most studies used pain and/or physical function as their primary outcome (n = 6). Music therapy showed a statistically significant reduction in visual analog scale score for pain, and there was a trend toward improvement of pain and function in the physical therapy studies. No significant differences in outcomes between intervention and control groups were observed in the multimodal studies. Conclusion: This review highlights the scarcity of evidence related to home-based health interventions in older people 75 years and older, living with chronic, noninflammatory musculoskeletal pain. The findings were that physical, psychotherapeutic, and multimodal interventions are usually well tolerated and can be delivered as a safe self-management option. There remains a substantial need for more high-quality research with wider range of home-based interventions and comprehensive assessment of outcomes for this age group.
... Acute muscular pain of the postural and locomotor system in general as well as acute myofascial pain in the narrower sense are among the most frequent reasons for pain-related presentations in medical practice and are responsible for the majority of pain causes in patients with so-called non-specific (low) back pain 1,2 . Due to a recent representative crosssectional analysis of the Robert-Koch Institute, the one-year prevalence of non-specific (low) back pain in Germany is 61.3% of the total population (females: 66.0% vs. males: 56.4%) 3 , and in approximately 85% of these patients back pain is classified as non-specific 4 . ...
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Objective: To evaluate efficacy and tolerability of the nonbenzodiazepine antispasmodic pridinol (PRI), as an add-on treatment in patients with muscle-related pain (MRP). Methods: Exploratory retrospective analysis of depersonalized routine data provided by the German Pain e-Registry (GPeR) focusing on pain intensity, pain-related disabilities in daily life, wellbeing, and drug-related adverse events (DRAEs).Primary endpoint based on a global response composite of a) a clinically relevant analgesic response (relative improvement ≥50% and/or absolute improvement ≥ the minimal clinical important difference) for pain intensity and disability in combination with b) an improvement in wellbeing (all at end of treatment vs. baseline), and c) lack of any DRAEs. Results: Between January 1, 2018, and December 31, 2020, the GPeR collected information on 121,803 pain patients of whom 1,133 (0.9%; 54.5% female, mean ± SD age: 53.9 ± 11.8 years) received add-on PRI for the treatment of (mostly acute) MRP originating predominantly in the (lower) back (43.2%), lower limb (26.4%) or should/neck (21.1%). Average daily dose was 7.8 ± 1.8 (median 9, range 1.5-13.5) mg, duration of treatment 12.0 ± 10.2 (median 7, range 3-63) days. In total, 666 patients (58.8%) reported a complete, 395 (34.9%) a partial and 72 (6.4%) patients no response - either because of lack of efficacy (n = 2, 0.2%) or DRAEs (n = 70, 6.2%). In response to PRI, 41.7% of patients documented a reduction of at least one other pain medication and 30.8% even the complete cessation of any other pharmacological pain treatments. Conclusion: Based on this real-world data of the German Pain e-Registry, add-on treatment with PRI in patients with acute MRP under real-world conditions in daily life was well tolerated and associated with an improvement of pain intensity, pain-related disabilities, and overall wellbeing.
... Synonymous with open field and rotarod assessments, human patients with radiculopathy have slower gait speed, shorter travel distances, and greater standing time similar to aged old mice (44)(45)(46)(47)200). Patients with LBP have increased movement evoked fatigue, decreased physical activity, as well as reduced flexibility (201). In humans, mechanical hyperalgesia may also be measured similar to algometers in mice with the application of force with gradual intensity to the patient's lower back (43). ...
Article
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Low back pain is a leading cause of disability worldwide and studies have demonstrated intervertebral disc (IVD) degeneration as a major risk factor. While many in vitro models have been developed and used to study IVD pathophysiology and therapeutic strategies, the etiology of IVD degeneration is a complex multifactorial process involving crosstalk of nearby tissues and systemic effects. Thus, the use of appropriate in vivo models is necessary to fully understand the associated molecular, structural, and functional changes and how they relate to pain. Mouse models have been widely adopted due to accessibility and ease of genetic manipulation compared to other animal models. Despite their small size, mice lumbar discs demonstrate significant similarities to the human IVD in terms of geometry, structure, and mechanical properties. While several different mouse models of IVD degeneration exist, greater standardization of the methods for inducing degeneration and the development of a consistent set of output measurements could allow mouse models to become a stronger tool for clinical translation. This article reviews current mouse models of IVD degeneration in the context of clinical translation and highlights a critical set of output measurements for studying disease pathology or screening regenerative therapies with an emphasis on pain phenotyping. First, we summarized and categorized these models into genetic, age-related, and mechanically induced. Then, the outcome parameters assessed in these models are compared including, molecular, cellular, functional/structural, and pain assessments for both evoked and spontaneous pain. These comparisons highlight a set of potential key parameters that can be used to validate the model and inform its utility to screen potential therapies for IVD degeneration and their translation to the human condition. As treatment of symptomatic pain is important, this review provides an emphasis on critical pain-like behavior assessments in mice and explores current behavioral assessments relevant to discogenic back pain. Overall, the specific research question was determined to be essential to identify the relevant model with histological staining, imaging, extracellular matrix composition, mechanics, and pain as critical parameters for assessing degeneration and regenerative strategies.
... According to one hypothesis impaired motor control (MC) and a lack of awareness of maladaptive movement patterns perpetuates LBP [35]. In previous studies patients with chronic LBP have signi cantly more positive tests in motor controls tests than pain free controls [14,16]. ...
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PURPOSE Pregnancy-related low back pain is common. Persistent postpartum abdominal diastasis recti may cause back pain and motor control dysfunction. The role of diastasis in pregnancy-related back pain is under debate. The aim of this study was to compare participants with increased symptoms after index pregnancy with those reporting no change in back pain or subjective movement control and analyzed their inter rectus distance (IRD). METHODS: This study is a case-control study of a cohort of women who had delivered a year earlier. We recruited participants with increased symptoms (n=14) after index pregnancy and controls (n=41) and recorded their inter rectus distance with ultrasound. A questionnaire was filled, and an ultrasound was performed two times for the study groups. RESULTS: At the baseline there was no significant difference in IRD between cases and controls (mean 2.45±1.01 cm and 2.09±1.03 cm respectively). A year after index pregnancy cases had significantly wider IRD than controls (mean 3.45±0.90 cm and 2.40±0.79 cm respectively). Motor control dysfunction tests were not associated with core stability problems or back pain in this cohort. There was a difference in sit-up test between cases and controls (mean 4.7±4.2 and 8.2±3.9 respectively). CONCLUSION Women who reported increased back pain and core instability after index pregnancy had wider inter rectus diameter compared to controls. In case group with more symptom after pregnancy the classification of ARD changed from mild abdominal rectus diastasis (2-3cm) to moderate (>3-5cm). Abdominal rectus diastasis may have a role in persistent pregnancy related lumbopelvic pain.
... O'Sullivan proposed a mechanism based organization dividing nonspecific low back pain into 3 subtypes supported pain provocative spinal postures and movement patterns. 3,4 Non-specific low back pain (NS-LBP) could be a major unhealthiness encountered by physiotherapists and other medical professionals in daily clinical practice. Approximately 84% of individuals encounter low back pain (LBP) in their lifetime, with a prevalence of roughly 23% 5 The recurrence of low back pain increases as age advances, and its prevalence within the elderly population old age 40 and older is as high as 20 to 40%. ...
Article
Aim:To find out prevalence of alteration in chest expansion among non-specific low back pain patients Background: The diaphragm is an essential muscle for breathing; however, it also has a role in preserving the segmental stability of the lumbar spine by maintaining and increasing the intra-abdominal pressure during postural tasks, diaphragm fatigue in LBP patients may compromise trunk muscle contribution to spinal control, leading to the development or recurrence of LBP or NSLBP, And these may affect chest expansion in NSLBP patients. Method:In this study 65 patients with non specific low back pain were recruited & screened according to inclusion and exclusion criteria from Jalgaon city. The age group of study range from 18-65 yrs. The data was collected by using convenient sampling method. Chest expansion was measured using cloth tape at three levels that is 2nd Intercostal Space, 4th Intercostal Space and xiphoid process. Result:The study showed 45 % patients with normal chest expansion values and 55 % patients with decreased chest expansion values out of 100%. Conclusion:The study concluded that there is a significant alteration in chest expansion among non-specific low back pain patients. This shows that non specific low back pain may affect chest expansion. Key words: Nonspecific low back pain, Chest expansion, Cloth tape
... The most common of LBP cases (85%) occur are Nonspecific LBP (3). Non-specific LBP is define as unknown pathophysiological causes (4). ...
Article
Introduction: The Inertial Measurement Unit (IMU) is electronic device that enabled us to record joint angles, gait event and spatiotemporal parameter using accelerometers. IMU contain sensors known as inertial sensor which measures its movement by using the inertia principle. This study aimed to determine validity and reliability of spatiotemporal gait parameter using the IMU sensor. Methods: This study are prospective cross-sectional recruited thirteen convenience subjects (four men, nine women; 50.0 +/-15.0 years) diagnosed with chronic Non-Specific Lower Back Pain (LBP) from Physiotherapy Department, upon an Orthopedic Specialist’s referral, at Hospital Sultanah Aminah Johor Bahru. Spatiotemporal parameters interested: left and right velocity, cadence, stride/step time and stride/step length recorded by Vicon system and IMU sensors synchronously. Results: Higher validity was indicated at the Trial 2 detected by the IMU sensors comparing Vicon system, with significant correlation p ≤ 0.05 except stride time left shank (r = 0.539, p = 0.06) , left foot (r = 0.495, p = 0.11) and step length left shank (r = 0.532, p = 0.06). The result of study also indicated that the reliability of the IMU sensors based on ICCs ≥ 0.75 and 95% CI 0.180 – 0.993, p ≤ 0.01 in Non-specific LBP patients for spatiotemporal gait parameters comparing Trial 1 and Trial 2. Conclusion: The IMU system performs to be valid and reliable for determine spatiotemporal gait parameters in Non-specific LBP patients. IMU provides a possible solution to measure spatiotemporal gait in a clinical setting without requiring specific working area and professional technician.
... Such cases are referred to as non-specific low back pain (NSLBP). 9,10 The prevalence of NSLBP was reported to be 6.6, 9.9 and 9.2% in the rural, urban slum and urban affluent community, respectively, in another small-scale study. 11 Although the causes of NSLBP is unknown, but there are some known factors (modifiable or non-modifiable) that are associated with NSLBP. ...
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Background: Data pertaining to risk factors of nonspecific low back pain (NSLBP) among rural Bangladeshi is scarce. This study explored the risk factors associated with NSLBP among rural Bangladeshi adults. Methods: A community-based study was done in Sonargaon Upazila of Narayanganj district of Bangladesh. A total of 343 NSLBP patients were recruited as cases, based on the Bangla version of Community oriented program for control of rheumatic diseases (COPCORD) questionnaire. An equal number of age and sex matched subjects without any rheumatic disease were recruited from the same community. A total of 15 probable factors were analyzed. Age-sex adjusted univariate and age-sex with 13 risk factors adjusted multivariate conditional logistic regression analyses were done. Results: The mean age of the participants was 33.1 years old (standard deviation: 9.5). Out of 13 risk factors, history of chronic disease (OR 2.0, 95% CI 1.2 – 3.4), prolonged sitting (OR 4.6, 95% CI 2.0 – 11.0), squatting (OR 7.2, 95% CI 3.2 – 16.0), bending of the waist (OR 3.7, 95% CI 1.8 – 7.6), regular lifting or carrying a heavy load (OR 9.2, 95% CI 2.2 – 39.7), prolonged standing (OR 5.8, 95% CI 1.9 – 17.7), occupation related to strenuous physical activity (OR 0.2, 95% CI 0.1 – 0.8), overweight (body mass index >=25 kg/m ² ) (OR 3.1, 95% CI 1.8 – 5.2) and depression (OR 2.2, 95% CI 1.4 – 3.6) were found to be significantly associated with NSLBP. Conclusions: The study generated knowledge on associated risk factors for NSLBP in rural people of Bangladesh that may facilitate an evidence-based intervention for the target group.
... A decreased level in physical activity negatively affects cardiovascular capacity, muscle strength and motor control [4]. Moreover, passive coping strategies, avoidant behaviour, catastrophizing and hypervigilance negatively influence pain level, mobility and muscle awareness, further contributing to deconditioning [5]. Patients opting for LSF are probably at various stages of deconditioning and those who are more deconditioned may be at increased risk of negative postoperative outcomes [6][7][8]. ...
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Purpose To explore risk profiles of patients scheduled for lumbar spinal fusion (LSF) and their association with short-term recovery of patient after surgery. Methods Forty-nine patients scheduled for elective 1–3 level LSF between March 2019 and June 2020 were included. Patients underwent a preoperative risk screening, consisting of an anamnesis, questionnaires and physical performance tests. A latent profile analysis (LPA) was used to identify possible risk profiles within this population. Results Two risk profiles could be established: a fit and deconditioned risk profile. A significant between-profile difference was found in smoking status (p = 0.007), RAND36-PCS (p < 0.001), Timed Up and Go (TUG) (p < 0.001), de Morton Morbidity Index (DEMMI) (p < 0.001), finger floor distance (p = 0.050), motor control (p = 0.020) and steep ramp test (p = 0.005). Moreover, the fit risk profile had a significant shorter time to functional recovery (3.65 days versus 4.89 days, p = 0.013) and length of hospital stay (5.06 days versus 6.00 days, p = 0.008) compared to the deconditioned risk profile. No differences in complication rates between both risk profiles could be established. Allocation to a risk profile was associated with the functional recovery rate (p = 0.042), but not with LOS or complications. Conclusion This study found a fit and deconditioned risk profile. The patients with a fit risk profile perceived a better quality of life, performed better in mobility, motor control, cardiopulmonary tests and showed also a significant shorter stay in the hospital and a shorter time to functional recovery. Preoperatively establishing a patient’s risk profile could aid in perioperative care planning and preoperative decision-making.
... Standardized clinical tests can be done to assess individualized lumbar movement, [1][2][3][4] including the potential association between lumbar motor control and the presentation of low back disorders. 2,5,6 Administering such tests in a telehealth setting poses additional challenges, given the lack of physical interaction between a patient and clinician, and the requirement to acquire reliable lumbar movement data using 2D video. Novel, computer vision approaches to track human movement are becoming more prevalent 7 ; however, many of these approaches have been used to track the motion of the upper and lower extremities. ...
Article
The purpose of this research was to evaluate the algorithm DeepLabCut (DLC) against a 3D motion capture system (Vicon Motion Systems Ltd) in the analysis of lumbar and elbow flexion–extension movements. Data were acquired concurrently and tracked using DLC and Vicon. A novel DLC model was trained using video data derived from a subset of participants (training group). Accuracy and precision were assessed using data derived from the training group as well as in a new set of participants (testing group). Two-way analysis of variance were used to detect significant differences between the training and testing sets, capture methods (Vicon vs DLC), as well as potential higher order interaction effect between these independent variables in the estimation of flexion–extension angles and variability. No significant differences were observed in any planar angles, nor were any higher order interactions observed between each motion capture modality with the training versus testing data sets. Bland– Altman plots were used to depict the mean bias and level of agreement between DLC and Vicon for both training and testing data sets. This research suggests that DLC-derived planar kinematics of both the elbow and lumbar spine are of acceptable accuracy and precision when compared with conventional laboratory gold standards (Vicon).
... It is known that alterations of the spine are also common in healthy subjects and in most cases not related to the patient's symptoms [2]. Research has shown that patients can be subclassified according to the clinical presentation to allow personalized approaches, demonstrating good results [7,8]. Biomechanics could play an important role among the biological factors of the bio-psycho-social cLBP syndrome. ...
Article
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This study aimed to assess the reliability of a qualitative scoring system based on the movement analysis of the spine in different populations and after usual care rehabilitative intervention. If proven true, the results could further future research development in quantitative indexes, leading to a possible subclassification of chronic low back pain (cLBP). Methods: This was a preliminary exploratory observational study. Data of an optoelectronic spine movement analysis from a pathological population (cLBP population, 5 male, 5 female, age 58 ± 16 years) were compared to young healthy participants (5M, 5F, age 22 ± 1) and were analysed via a new qualitative score of the pattern of movement. Internal consistency was calculated. Two independent assessors (experienced and inexperienced) assessed the blinded data, and we calculated inter- and intrarater reliability. We performed an analysis for cLBP pre and post a ten session group rehabilitation program between and within groups. Results: Internal consistency was good for all movements (α = 0.84–0.88). Intra-rater reliability (Intraclass correlation coefficient–ICC) was excellent for overall scores of all movements (ICC(1,k) = 0.95–0.99), while inter-rater reliability was poor to moderate (ICC(1,k) = 0.39–0.78). We found a significant difference in the total movement scores between cLBP and healthy participants (p = 0.001). Within-group comparison (cLBP) showed no significant difference in the total movement score in pre and post-treatment. Conclusion: The perception of differences between normal and pathological movements has been confirmed through the proposed scoring system, which proved to be able to distinguish different populations. This study has many limitations, but these results show that movement analysis could be a useful tool and open the door to quantifying the identified parameters through future studies.
... According to studies conducted in line with "uses and gratifications approach" (Katz, Blumler, & Gurevitch, 1973), there are a large number of motives underlying the use of social media. People utilize social media platforms for communication and social interaction (Cheng et al., 2014;Kim et al., 2011;Lee et al., 2015;Yenilmez Kacar, 2021) either through interpersonal or "masspersonal" communication applications (O'Sullivan, 2005), information seeking (Boztepe Taskiran, 2019; Leung, 2013;Throuvala et al., 2019), information dissemination (Johnson & Yang, 2009;Smock et al., 2011), entertainment (Cheng et al., 2014;Leung, 2013), relaxation (Gadekar & Krishnatray, 2017;Smock et al., 2011), surveillance (Cheng et al., 2014;Malik et al., 2015) and affection seeking purposes (Apodaca, 2017;Sung et al., 2016), etc. ...
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COVID-19 salgını sırasında, uzun süreli sosyal izolasyon ve sokağa çıkma kısıtlamaları nedeniyle sosyal medya başlıca sosyal etkileşim ve iletişim aracı haline gelmiş ve bu nedenle sosyal medya kullanımında önemli bir artış yaşanmıştır. Bundan hareketle, sosyal medya kullanımının yalnızlık hissini hafifleterek ruh sağlığı üzerinde olumlu bir etkisi olduğu varsayılmaktadır. Mevcut çalışma, pandemi döneminde sosyal medya kullanımı ile yalnızlık arasındaki ilişkiyi araştırmayı ve buna ilişkin bir model önermeyi amaçlamaktadır. Bu hedef doğrultusunda 178 katılımcıya online anket uygulanmış ve ilgili istatistiksel analizler SPSS 22.0 üzerinde yapılmıştır. Bulgular, sosyal medya kullanımı (sosyal medyada geçirilen zaman, takipçi sayısı, hesap sayısı) ile yalnızlık arasında negatif bir ilişki olduğunu ortaya koymuştur. Çalışma sosyal medyanın pandemi sırasındaki sosyal izolasyonun neden olduğu yalnızlığı azaltmak için etkili bir sosyal etkileşim platformu olarak kullanılabileceğini ortaya koymuştur.
... It is considered a health condition that needs a multidisciplinary rehabilitation approach to be managed [16]. Despite the motor control impairment affecting people with cLBP [17], to the best of our knowledge, it has not yet been explored using the iTUG. ...
Article
Purpose To analyze temporal and kinematic parameters of chronic Low-Back Pain (cLBP) subjects compared to healthy subjects during Timed Up and Go Test (TUG) execution implemented with an Inertial Measurement Unit and to explore the correlations of those parameters with pain and disability. Methods Observational cross-sectional study. Thirty-one subjects with cLBP [(19 females - 61%), mean age 61±19] were allocated to the case group, and 14 healthy [(10 females - 71%), mean age 62 ± 6] subjects to the control group. Instrumented TUG was administered to both groups. The Roland Morris Disability Questionnaire and Numerical Pain Rating Scale (NPRS) were also administered for disability and pain assessment in the case group. Results Mean TUG time to completion [12.2 ± 3.5 s for cLBP; 8.1 ± 0.9 s for healthy] and the most of sub-phases duration significantly differed between groups (p<0.05). As for kinematic parameters, significant differences (p<0.05) were mainly retrieved in acceleration components during the sit-to-stand and stand-to-sit phase, with the cLBP group showing lower accelerations. Significant correlation [from strong (ρ = 0.75 of time to completion) to moderate (ρ = 0.43 of sit-to-stand)] was observed between RMQD score and all temporal parameters and with most of the kinematic parameters. No correlation with NPRS score was found. Conclusions Instrumented TUG application into a cLBP population provides valuable information about movement behaviors with a deeper assessment of objective functional impairment and disability in respect of the classical stop-watch outcome of TUG, possibly allowing a better design of the rehabilitative intervention.
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Despite a large body of evidence demonstrating spinal movement alterations in individuals with chronic low back pain (CLBP), there is still a lack of understanding of the role of spinal movement behavior on LBP symptoms development or recovery. One reason for this may be that spinal movement has been studied during various functional tasks without knowing if the tasks are interchangeable, limiting data consolidation steps. The first objective of this cross-sectional study was to analyze the influence of the functional tasks on the information carried by spinal movement measures. To this end, we first analyzed the relationships in spinal movement between various functional tasks in patients with CLBP using Pearson correlations. Second, we compared the performance of spinal movement measures to differentiate patients with CLBP from asymptomatic controls among tasks. The second objective of the study was to develop task-independent measures of spinal movement and determine the construct validity of the approach. Five functional tasks primarily involving sagittal-plane movement were recorded for 52 patients with CLBP and 20 asymptomatic controls. Twelve measures were used to describe the sagittal-plane angular amplitude and velocity at the lower and upper lumbar spine as well as the activity of the erector spinae. Correlations between tasks were statistically significant in 91 out of 99 cases (0.31 ≤ r ≤ 0.96, all p < 0.05). The area under the curve (AUC) to differentiate groups did not differ substantially between tasks in most of the comparisons (82% had a difference in AUC of ≤0.1). The task-independent measures of spinal movement demonstrated equivalent or higher performance to differentiate groups than functional tasks alone. In conclusion, these findings support the existence of an individual spinal movement signature in patients with CLBP, and a limited influence of the tasks on the information carried by the movement measures, at least for the twelve common sagittal-plane measures analysed in this study. Therefore, this work brought critical insight for the interpretation of data in literature reporting differing tasks and for the design of future studies. The results also supported the construct validity of task-independent measures of spinal movement and encouraged its consideration in the future.
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Objective: To determine if classification systems improve patient-reported outcomes for people with low back pain (LBP). Design: Systematic review with meta-analysis. Literature search: MEDLINE, EMBASE, CINAHL, Web of Science Core Collection and CENTRAL were searched from inception to 21 June, 2021. Reference lists of prior systematic reviews and included trials were screened. Study selection criteria: We included randomized trials comparing a classification system (e.g. McKenzie and STarT Back Tool) to any comparator. Studies evaluating participants with specific spinal conditions (e.g. fractures and tumors) were excluded. Data synthesis: Outcomes were patient-reported LBP intensity, leg pain intensity and disability. We used the Cochrane RoB2 tool to assess risk of bias, and the GRADE approach to judge the certainty of evidence. We used random effects meta-analysis with Hartung-Knapp-Sidik-Jonkman adjustment to estimate standardized mean differences (Hedges g) and 95% confidence intervals (95%CI). Sub-group analyses explored classification systems, comparator type, pain type and duration. Results: Twenty-four trials assessing classification systems and 34 assessing sub classes were included. There was low certainty of a small effect at end of intervention for LBP intensity (-0.31[-0.54,-0.07], p=0.014, n=4416, trials=21) and disability (0.27[ 0.46,-0.07], p=0.011, n=4809, trials=24) favoring classified treatments compared to generalized interventions, but not for leg pain intensity. At the end of intervention, no specific type of classification system was superior to generalized interventions for improving pain intensity and disability. None of the estimates exceeded the effect size that one would consider clinically meaningful. Conclusions: For patient-reported pain intensity and disability, there is insufficient evidence supporting the use of classification systems above generalized interventions when managing LBP. J Orthop Sports Phys Ther, Epub 15 Nov 2021. doi:10.2519/jospt.2022.10761.
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Introduction Chronic low back pain (CLBP) is one of the most common disorders presenting in primary healthcare. Kinematic studies of low lumbar pelvic mobility allied with surface electromyography (sEMG) may assist in the assessment and management of CLBP. However, the applicability in the use of sEMG in the clinical setting remains uncertain. In this protocol, we aim to review the clinical utility and reproducibility of the sEMG component of these kinematic studies in patients with CLBP. Methods and analysis This protocol was informed by the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) and results will be reported in line with the PRISMA. Searches will be conducted on PubMed, Scopus, Web of Science, Embase, CINAHL and Google Scholar databases, along with a comprehensive review of grey literature. Two reviewers will conduct the searches and independently screen them, according to title and abstract. Two independent reviewers will then assess the full-text versions of those selected articles and assess the risk of bias using the defined protocol inclusion criteria. The risk of bias within the studies included will be assessed via the Quality Assessment of Diagnostic Accuracy Studies tool, V.2 and the Grading of Recommendations Assessment, Development and Evaluation guidelines will be used to assess certainty of evidence for recommendations based on the risk of bias findings. Meta-analysis will be conducted where appropriate on groups of studies with low heterogeneity. In instances of higher heterogeneity, meta-synthesis will instead be completed, comparing results in terms of increased or decreased clinical utility and/or reproducibility of sEMG. Ethics and dissemination Ethics approval was not required for this research. It is anticipated that the results will influence the use, interpretation and further development of sEMG in management and assessment of these patients.
Chapter
Neuromodulation techniques for pain treatment have been used since ancient Rome, but knowledge about the interaction of electricity and drugs with the central nervous system (electrical and chemical neuromodulation) was not clear until the middle of the twentieth century. It was only then that the advent of neuromodulatory techniques allowed for more widespread clinical application for the treatment of several neurological and psychiatric conditions, including pain. In this chapter, we present the history of neuromodulation techniques for the treatment of pain, from its first applications to a more organized approach encompassing physiological and technological improvements producing the current concepts in neuromodulation. We also take an in-depth look at the current surgical techniques for neuromodulatory improvement of pain.
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Background: social distancing was implemented worldwide due to the coronavirus (COVID-19) pandemic. This impacted physical activity levels and increased the time spent in sedentary behaviors which may contributed to the emergence of increased musculoskeletal complaints. Objective: To assess the consequences of social distancing for the increase in perceived pain of students and professors from higher education institutions. Methods: One thousand two hundred and fifty-four participants responded to an online survey containing sociodemographic information and questions related to daily habits, physical activity profile, and musculoskeletal pain before and during the pandemic. Level of concentration, nervousness, productivity, and visual fatigue were also assessed. The primary outcome was presence of perceived pain before and during the pandemic, dichotomized between those with and without increased pain during the pandemic. Results: perceived pain increased during the pandemic (p < 0.001) and was associated with females (p = 0.023; PR = 1.16; 95% CI = 1.02-1.32), income up to one minimum wage (p = 0.039; PR = 1.20; 95% CI = 1.01-1.42), no physical activity practice (p = 0.006; PR = 1.22; 95% CI = 1.06-1.40), long time in sedentary behavior (p = 0.013; PR = 3.07; 95% CI = 1.27-7.43), and electronic device usage for > 6 hours (p = 0.041; PR = 1.44; 95% CI = 1.02-2.06). Nervousness (p = 0.001) and visual fatigue (p = 0.001) increased, whereas concentration (p = 0.001) and productivity (p = 0.001) reduced during the pandemic. Conclusions: reduced physical activity practice and increased time in sedentary behavior and electronic device usage during the pandemic were associated with increased musculoskeletal pain in students and professors from higher education institutions. Decreased concentration and productivity and increased nervousness and visual fatigue were also observed during the pandemic.
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Preface of the Brazilian version of the ICOP It is with great satisfaction and enthusiasm that we present the Portuguese version of the ICOP (International Classification of Orofacial Pain, in English). ICOP is the result of an effort by several world representative entities in the area of Orofacial Pain. That initiative culminated in a comprehensive document that aims to standardize the classification of Orofacial Pain. Originally published in 2020 by the International Headache Society (IHS), we now have our version in Portuguese, to be applied in research and clinical activities, also providing subsidies to discuss future steps. The ICOP is formatted in such a way that it provides a logical and coherent flow of reasoning for determining the diagnosis. We must also remember that this document is part of the initiative of the World Health Organization (WHO), through the International Classification of Diseases (ICD), and should be part of the entity's official document from 2022, which makes it even more important as a tool for “conversation” with other health specialties involved in the diagnosis and treatment of pain. We would like to say a huge thank you to all the members of the Committee involved in the translation process and especially the Brazilian Headache Society (SBCe) for their support for the materialization of this project. We also thank Cephalalgia for allowing the translation of the ICOP originally published by them, and the publication of the Brazilian version. We also emphasize that this is a “beta” version of the ICOP, which means that it must undergo adjustments and improvements after a period of use. Thus, we invite all of you to use, discuss, apply the criteria and, above all, give your opinion so that we can always take another step forward in the difficult but fundamental task of classifying Orofacial Pain. Good reading!
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Resumen El desafío diario del clínico es le cuidado del paciente como individuo. ¿Cómo integrar la mejor evidencia científica disponible con la experiencia clínica del terapeuta y con los valores y las preferencias del paciente que sufre una lumbalgia inespecífica? Una vez descartadas las posibles causas específicas, ¿cómo adaptar el tratamiento del paciente en función de sus posibilidades de recuperación y de los resultados probables del tratamiento? Este artículo presenta el razonamiento clínico detallado del fisioterapeuta, así como una argumentación exhaustiva para cara etapa del tratamiento de una paciente que presenta dolor lumbar clasificado como «lumbalgia inespecífica con ciatalgia con bajo riesgo de cronificación». Desde la evaluación subjetiva hasta el tratamiento, pasando por una exploración física detallada y estructurada, este caso clínico es el reflejo de una población de pacientes que se observa a menudo en la consulta.
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Functional restoration (FR) describes a therapeutic principle for addressing chronic pain that aims to improve subjective and objective functioning at the somatic and psychosocial levels. The principle, which is based on a biopsychosocial pain model and a holistic, interdisciplinary approach to treatment, is now the basis for practically all interdisciplinary pain therapy programs. Diagnosis and treatment are provided on an interdisciplinary basis by a permanent team with spatial, temporal, and conceptual integration. Structural pathologies, somatic dysfunction, psychosocial dysfunction, and medical and psychological/psychiatric comorbidities are to be recorded and evaluated in terms of their significance for the pain problem. The patient’s individual, conceptually uniform treatment plan results from this overall consideration. In addition to an improvement in somatic performance, a change in dysfunctional patterns at the psychosocial level is necessary for sustainable therapeutic success. In all care sectors, FR according to the described principles is effective in the long term for different pain disorders—in children and adolescents as well as in geriatric patients.
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The purpose of study was to compare the kinematic patterns of the thoracic, lumbar, and pelvis segments and hip joints between 2 low back pain subgroups and healthy women during sit-to-stand and stand-to-sit. Kinematic data of 44 healthy women and 2 subgroups of females with low back pain in 2 subgroups of movement system impairment model (rotation-extension [Rot.Ext] and rotation-flexion [Rot.Flex]) were recorded. Participants performed sit-to-stand and stand-to-sit at a preferred speed. Each task was divided into a pre buttock lifted off/on (pre-BO ff/n ) phase and a post-BO ff/n phase. The Rot.Ext subgroup showed greater range of motion in the thoracic during pre-BO ff phase of sit-to-stand ( P < .001) and pre-BO n phase of stand-to-sit ( P = .01) compared to the other 2 groups. The Rot.Flex subgroup displayed limited left hip joint excursion during sit-to-stand pre-BO ff ( P = .04) and stand-to-sit post-BO n phases ( P = .02). The Rot.Flex subgroup showed greater pelvis tilt excursion during sit-to-stand post-BO ff ( P = .04) and stand-to-sit pre-BO n ( P = .01) and post-BO n phases ( P = .01). In subgroups of women with chronic low back pain, there were kinematic changes in adjacent body segments/joints of lumbar spine during sit-to-stand and stand-to-sit tasks.
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Objective: To evaluate the impact of treatment with Ipigrix on the dynamics of clinical symptoms, neurological status, and quality of life in patients with dorsalgia of the lumbosacral spine based on the DORISS non-interventional multicenter observational study. Material and methods: A total of 3563 patients with verified diagnoses of low back pain in 200 clinical centers across the Russian Federation who received comparable baseline therapy according to nosological standards were examined, some of whom additionally received oral or staged administration of Ipigrix. The primary endpoint of the study was the description of clinical and sociodemographic parameters, the consumption of medical resources, and the search for optimization of dorsalgia diagnosis in contemporary Russian outpatient neurological practice. Results: The population of patients included in the study represents a homogeneous group of educated, overweight people of working age with average severity of low back pain and related dysfunction. In 91.6% of cases nonspecific mechanisms of pain syndrome development with a moderate neuropathic component prevail in the genesis of back pain, being a reason for seeking medical advice once every 2 months on average. The overdiagnosis of lumbar radiculopathies is discussed, which most probably is of combined nature due to overuse and straightforward interpretation of neuroimaging results, nonsyndromological diagnosis, and classification defects. Conclusion: Improving the methods of diagnosis and treatment of patients with PB will reduce the incidence and the number of relapses of pain syndrome.
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Background To find effective treatments for low back pain remains a major challenge in physical therapy. Numerous treatment methods currently exist, but the use of real-time visual feedback is a promising new therapeutic approach. The opportunities for its implementation and use require further research. Objective To develop a video-supported system for visual feedback and to test its usability. Method The prototype of a video-based system for visual feedback was developed and tested on a person with persistent unspecific lumbar back pain. The system was evaluated through an interview with the subject and the system usability scale (SUS). Results The subject was optimistic about the system’s functionality. He was astonished to see his own back while moving, which triggered positive emotions. He also found the apparatus comfortable to wear. The system achieved a value of 77.5 out of 100 on the SUS, which represents good usability. Conclusion By means of technical adjustments to avoid a delay in transmission and an exact positioning of the monitor, further improvements in the usability can be achieved. More research will be required to evaluate the efficacy of the developed system in the treatment of lumbar back pain.
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Introduction: The deep fascia is a three-dimensional continuum of connective tissue surrounding the bones, muscles, nerves and blood vessels throughout our body. Its importance in chronically debilitating conditions has recently been brought to light. This work investigates changes in these tissues in pathological settings. Materials and methods: A state-of-the-art review was conducted in PubMed and Google Scholar following a two-stage process. A first search was performed to identify main types of deep fasciae. A second search was performed to identify studies considering a deep fascia, common pathologies of this deep fascia and the associated alterations in tissue anatomy. Results: We find that five main deep fasciae pathologies are chronic low back pain, chronic neck pain, Dupuytren's disease, plantar fasciitis and iliotibial band syndrome. The corresponding fasciae are respectively the thoracolumbar fascia, the cervical fascia, the palmar fascia, the plantar fascia and the iliotibial tract. Pathological fascia is characterized by increased tissue stiffness along with alterations in myofibroblast activity and the extra-cellular matrix, both in terms of collagen and Matrix Metalloproteases (MMP) levels. Innervation changes such as increased density and sensitization of nociceptive nerve fibers are observed. Additionally, markers of inflammation such as pro-inflammatory cytokines and immune cells are documented. Pain originating from the deep fascia likely results from a combination of increased nerve density, sensitization and chronic nociceptive stimulation, whether physical or chemical. Conclusions: The pathological fascia is characterized by changes in innervation, immunology and tissue contracture. Further investigation is required to best benefit both research opportunities and patient care.
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Low back pain (LBP) is a global health-problem phenomenon. Most patients are categorized as non-specific, thus requiring an individualized approach which still poses a major challenge. In this paper, sEMG recordings from two pairs of lumbar muscle sites were collected during an isometric trunk extension exercise. Ninety-one subjects were included in the study; 29 patients with non-specific chronic LBP (CLBP), 25 patients with radiculopathy (RLBP), and 37 control healthy subjects (HS). Six best-performing time-domain raw features were employed to model contextual secondary feature groups. Neuromuscular LBP characteristics were described with coordination, co-activation, trends, and fatigue measures. Altogether, a set of 327 secondary features was created where inputs into the classification models were further refined by employing neighborhood component analysis (NCA). NCA effectively reduced the number of features (<20 components), alongside preserving them in the original interpretable domain. A set of 23 different classifiers was employed and explored, resulting in classification accuracy of 0.94 for HS vs. LBP, 0.89 for HS vs. CLBP, 0.98 for HS vs. RLBP, and 0.89 for CLBP vs. RLBP differentiation. High median precision (0.97) and sensitivity (0.99) across all classifiers for HS vs. RLBP differentiation was obtained, with only three feature components utilized (out of 327). Support vector machines (SVM) and ${k}$ -nearest neighbor ( ${k}$ NN) based classifiers consistently demonstrated best classification results. Different profiles of CLBP patients were presented and discussed. The suggested method demonstrated the potential for patients’ subgrouping and subsequent more individualized rehabilitation treatments, backed by medical interpretations through feature modeling.
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Introduction Low back pain (LBP) is the leading cause of years lived with disability worldwide. Higher levels of catastrophizing were found in patients with LBP and this variable is associated with self-reported disability. The Pain Catastrophizing Scale (PCS) is a self-report questionnaire that assesses catastrophizing in the presence of pain. Currently, an Argentine version of the PCS is not available. Objective To translate and cross-culturally adapt the PCS into Argentine Spanish and test the psychometric properties of the new version with chronic LBP patients. Study design Study of diagnostic accuracy/assessment scale. Methods The study was carried out in three consecutive phases following the COSMIN guidelines: translation, cross-cultural adaptation and validation. We included Argentine residents over 18 years with chronic LBP. We used the PCS and the Global rating of change (GROC) to assess the psychometric properties. Results No difficulties were present in the translation processes and the PCS-Arg was developed. The alfa Cronbach coefficient was 0.89. The standard error of measurement and the minimal detectable change were 5.4 and 15.1 points, respectively. In the explanatory factorial analysis 3 components were identified. For the construct validity, the correlation between the PCS-Arg and disability and pain were r = 0.35 and rho = 0.04, respectively. The mean PCS score was 29.9. The lowest and highest scores were 3 and 52 points, therefore, no roof or ceiling effects of the total score were observed. Conclusion The PCS-Arg is a viable, reliable and valid tool for the assessment of catastrophizing in patients with chronic LBP.
Article
Objective: To compare muscle strength and flexibility among a subgroup of women with extension-related chronic nonspecific low back pain (CNLBP) with healthy controls. Methods: In this case-control study, 32 subjects with and without extension-related CNLBP were tested (n = 16 in each group). Gluteal, abdominal, paravertebral, and hamstring strength, along with hip flexor flexibility and hamstring flexibility were compared between groups. Data were analyzed using the Mann-Whitney test (p < .007). Results: The CNLBP subgroup displayed significantly lower strength of all muscles analyzed (p < .007), with the exception of gluteus medius. The flexibility of the hip flexors and hamstrings were not significantly reduced among the women with CNLBP (p > .007). Discussion: The present study showed that alterations in muscle strength, but not flexibility, partly consistent with those previously hypothesized but not objectively reported, were present among a subgroup of women with extension-related CNLBP. These results may have implications for the selection of therapeutic exercises among this subgroup of people with CNLBP.
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Background Chronic low back pain due to manual lifting continues to be one of the significant common public health challenges in modern societies despite increased automation. While there are extensive studies on the biomechanics of lifting as associated with LBP, the role of unstable and time-varying dynamic loads, quite common in industrial lifting and daily life, remains elusive. Objectives The present study aimed to investigate the response of trunk muscles in subjects with chronic non-specific low back pain (CNLBP) while holding unstable dynamic loads. Methods Twelve male patients with CNLBP and twelve healthy controls participated in this cross-sectional study. The subjects held static and dynamic loads in neutral positions. Normalized EMG data of the trunk muscles were captured and analyzed by repeated-measures ANOVA test. Results The low back pain group demonstrated significantly higher activation levels of the internal and external abdominal oblique muscles while holding dynamic loads (p < 0.05). Conclusion Our results suggest that the neuromusculoskeletal system in low back patients holding dynamic loads may invoke a motor control strategy that significantly increases muscle co-activation leading to higher joint stiffness at the expense of higher compressive loads on the lumbar spine. Importantly, the type of load plays a critical role in terms of external perturbations that may lead to spinal injury in CNLBP patients and must, therefore, be considered in the risk prevention and assessment of lifting and other manual material handling tasks.
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Background and Aims Multiple Sclerosis (MS) is one of the most common destructive diseases of the central nervous system, which leads to disability and impaired mobility and functional capacity in patients. For the rehabilitation of patients with MS, resistance training is considered as a safe and efficient method. In this regard, in recent years, core stability exercise has become one of the common training methods for the rehabilitation of patients with MS. It is defined as the ability to control the position of the trunk over the pelvis to effectively transfer the force to the lower extremities during various activities. This study aims to compare the effects of selected TRX and aerofitness exercises on the core stability of women with MS. Methods In this randomized clinical trial, 30 women with MS aged 20-50 years with expanded disability status scale score <5 referred to MS Association of Isfahan were selected by a purposive sampling method and were randomly divided into two TRX and aerofitness groups. They performed the exercises for 8 weeks, 3 sessions per week, each for 60 minutes. Their core stability was measured using the Biering-Sørensen test, isometric lateral trunk endurance tests, and Planck test. Data were analyzed using paired t-test and independent t-test. Results The selected TRX and aerofitness exercises had a significant effect on the improvement of core stability in women with MS (P <0.05). Patients in the TRX group showed more significant improvement than in the aerofitness group (P <0.05). Conclusion The selected TRX and aerofitness exercises can improve the core stability of women with MS. However, further studies are needed to use these exercises in patients with MS.
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Study design: Numerous authors have attempted to sub-classify low back pain in order that valid homogenous subsets of low back pain presentations might be recognised. This review systematically appraises these papers. Methods: Medline, Embase, Cinahl, AMED and PEDro electronic databases were searched with subsequent hand searching of bibliographies. Papers were included between June 1983 and June 2003. Two reviewers independently reviewed 32 papers using a standard scoring criteria for assessment. A third reviewer mediated disagreements. Results: Thirty-two papers were reviewed, with classification systems being grouped by method of classification. Classification has been attempted by implication of patho-anatomical source, by clinical features, by psychological features, by health and work status and in one case by a biopsychosocial weighting system. Scores were generally higher for systems using a statistical cluster analysis approach to classification than a judgemental approach. Both approaches have specific advantages and disadvantages with a synthesis of both methodologies being most likely to generate an optimal classification system. Conclusions: The classification of NSLBP has traditionally involved the use of one paradigm. In the present era of biopsychosocial management of NSLBP, there is a need for an integrated classification system that will allow rational assessment of NSLBP from biomedical, psychological and social constructs.
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Study Design: A prospective cross-sectional analytic approach was taken Objectives: This study sought to determine the relative contribution of the disc and the zygapophyseal joint as a pain source in patients with chronic low back pain. Summary of Background Data: Previous studies have employed either zygapophyseal joint blocks or discography, but in no studies have both procedures been performed. Methods: Ninety-two consecutive patients with chronic low back pain were studied using both discography and blocks of the zygapophyseal joints. Results: Thirty-six patients (39%) had at least one positive discogram as defined by exact pain reproduction, an abnormal image, and a negative control. Eight patients responded to both a screening zygapophyseal joint block using lignocaine and a confirmatory block using bupivicaine. Only three patients had both a positive discogram and a symptomatic zygapophyseal joint. Conclusions: In patients with chronic low back pain, the combination of discogenic pain and zygapophyseal joint pain is uncommon.
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To assess the inter-rater reliability of seven pain provocation tests for pain of sacroiliac origin in low back pain patients. Previous studies on the reliability of such tests have produced inconclusive and conflicting results. Fifty-one patients with low back pain, with or without radiation into the lower limb, were assessed by one examiner and another drawn from a pool of five. Percent agreement and the Kappa statistic were used to evaluate the reliability of the seven tests. Percent agreement and the Kappa statistic ranged in value from 78% and 0.52 (P < 0.001) to 94% and 0.88 (P < 0.001), respectively, when results for all examiner pairs were pooled. However, two tests demonstrated only marginal reliability when performed by one pair of assessors that examined 43% of the patients. Five of seven tests employed in this study were reliable, the other two were potentially reliable. These tests may be used to detect a sacroiliac source of low back pain, although sensitivity and specificity studies are needed to determine their diagnostic power.
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To investigate the claim that 90% of episodes of low back pain that present to general practice have resolved within one month. Prospective study of all adults consulting in general practice because of low back pain over 12 months with follow up at 1 week, 3 months, and 12 months after consultation. Two general practices in south Manchester. 490 subjects (203 men, 287 women) aged 18-75 years. Proportion of patients who have ceased to consult with low back pain after 3 months; proportion of patients who are free of pain and back related disability at 3 and 12 months. Annual cumulative consultation rate among adults in the practices was 6.4%. Of the 463 patients who consulted with a new episode of low back pain, 275 (59%) had only a single consultation, and 150 (32%) had repeat consultations confined to the 3 months after initial consultation. However, of those interviewed at 3 and 12 months follow up, only 39/188 (21%) and 42/170 (25%) respectively had completely recovered in terms of pain and disability. The results are consistent with the interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months. However most will still be experiencing low back pain and related disability one year after consultation.
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This paper provides an analysis of the literature on trunk muscle recruitment in low-back pain patients. Two models proposed in the literature, the pain-spasm-pain model and the pain adaptation model, yield conflicting predictions on how low- back pain would affect trunk muscle recruitment in various activities. The two models are outlined and evidence for the two from neurophsysiological studies is reviewed. Subsequently, specific predictions with respect to changes in activation of the lumbar extensor musculature are derived from both models. These predictions are compared to the results from 30 clinical studies and three induced pain studies retrieved in a comprehensive literature search. Neither of the two models is unequivocally supported by the literature. These data and further data on timing of muscle activity and load sharing between muscles suggest an alternative model to explain the alterations of trunk muscle recruitment due to low-back pain. It is proposed that motor control changes in patients are functional in that they enhance spinal stability.
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Study Design. Review of advances in the primary care research on low back pain (LBP) from a unique international forum, and analysis of open-ended questionnaires from participants. Summary of Background Data. LBP continues to be one of the most common and challenging problems in primary care. It is associated with enormous costs in terms of direct health care expenditures, and indirect work and disability-related losses. Objective. To ascertain the current status and state of the art regarding LBP in primary care. Methods. Four reviewers independently assessed the content and implications of presentations at the Fourth International Forum for Primary Care Research on LBP, pooled the data, and then augmented it with open-ended questionnaires completed by 35 participants. Results. The Fourth Forum documented the field’s emergent new paradigm–a transition from thinking about back pain as a biomedical “injury” to viewing LBP as a multifactorial biopsychosocial pain syndrome. The paradigm shift has occurred in the context of increased interest in evidence-based medicine regarding LBP in primary care. The Forum demonstrated the strides taken in moving from research and evidence gathering, through guidelines and policy formulations and finally to the dissemination and implementation imperative. There was an increasing confidence among the Forum researchers that LBP can be managed successfully in primary care settings through a combination of encouraging activity, reassurance, short-term symptom control, and alteration of inappropriate beliefs about the correlations of back pain with impairment and disability. There is also recognition that a wide range of international, evidence-based guidelines now exists that have very similar messages. Conclusions. The Fourth Forum reflected a major shift in the conceptualization of LBP in primary care and an increased emphasis on implementation and dissemination of LBP research findings and clinical guidelines. Although there is a wide array of challenges ahead, the Fourth Forum provided a clear message regarding the need to focus research energies on changing practitioner behavior.
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Despite increasing advances in medical technology, the cost of musculoskeletal incapacity, particularly low-back pain, in terms of sickness benefits, invalidity benefits and associated allowances has led to a fundamental reconsideration of the nature of chronic incapacity. Recent reports from the United Kingdom and the United States of America, in their recommendations for a comprehensive multidisciplinary assessment for patients still symptomatic at six weeks, are based on the clear assumption that a significant proportion of chronic incapacity is preventable. Such a proposition represents a fundamental challenge to much of current medical practice.
Article
The aim of this study was to identify reliable and valid subgroups of spinal pain patients, using data from the Swedish version of the Multidimensional Pain Inventory (MPI-S). A second aim was to test the generalisability of the three patient profiles described in earlier studies on the MPI (”adaptive coper”, ”dysfunctional” and ”interpersonally distressed” patients). The study base consisted of two samples of individuals suffering from long-term, non-specific spinal pain and the results were validated across these samples. Cluster analysis was used to detect distinct groups of patients and the validity of these subgroups was evaluated on variables not used to generate the cluster solution. One subgroup was characterised by lower pain severity, lower interference with everyday activities, lower affective distress and higher life control than the other two subgroups. This patient profile was similar to the MPI adaptive coper patients. A second subgroup resembled the dysfunctional patient profile, thus displaying a worse adjustment to chronic pain than the AC patients. The third patient group reported significantly lower levels of social support from “significant others” than the other subgroups. This patient profile was similar to that of the interpersonally distressed patient group. Taken together, the results support the reliability, validity and generalisability of three subgroups of chronic pain patients derived from the MPI-S.
Article
Abstract This paper comprehensively reviews the literature regarding evidence of neuro-muscular dysfunction associated with low back pain (LBP). From this review it is clear that neuro-muscular dysfunction occurs in the presence of LBP, although the manner of the dysfunction is variable. LBP is sometimes associated with a loss of strength and often a loss of endurance of the trunk muscles. LBP is commonly associated with varied and complex patterns of neuro-muscular dysfunction both between and within trunk muscle synergies. This results in disrupted patterns of co-contraction and co-ordination between and within trunk synergists and appears to reflect altered patterns of neuro-motor control. There is also evidence that the muscles commonly affected are those whose primary role is to provide segmental control and dynamic stability to the spine. Implications for the treating therapist regarding the management and rehabilitation of patients with LBP are broadly discussed. Keywords: Keywords Abdominal Muscles; Back Muscles; Electromyography; Low Back Pain; Muscle Dysfunction; Muscle Recruitment
Article
There are now many studies suggesting a positive relationship between both low back pain and spinal degeneration and exposure to whole body vibration. Such relationships appear to be particularly marked in drivers of tractors, earth-moving equipment, and trucks. There is a tendency toward a greater incidence of complaints as exposure increases. Vibration affects the spine by exciting a 4-6-Hz resonance that is related to the biologic "soft spring" between S-1 and the seat. The muscle nerves fire sequentially under vibration and fatigue. In animals, vibration exposure leads to pronounced creep, increased disk pressure, and changes in the levels of neuropeptides in the dorsal root ganglia.
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Unlabelled: Biomechanical tests, physical examination, spinal radiographs, a modified Minnesota Multiphasic Personality Inventory (MMPI), and a psychologic health inventory derived from the Hopkins Symptom Checklist were applied in 321 randomly selected men, ages 18-55. Each subject was evaluated for prior and current low-back pain (LBP) complaints by use of a modification of the McGill pain questionnaire. Subjects were then categorized as having no LBP (n = 106, 33%), moderate LBP (n = 144, 44.8%), and severe LBP (n = 71, 22.1%). Subjects were further subcategorized as not disabled (defined as equal or less than seven days of work lost in the previous year) and disabled (work loss greater than seven days in the prior year). Results: cumulative scores of the Hopkins Checklist showed that a mean score for no LBP equaled 2.5 +/- 2.9; moderate LBP was 4.3 +/- 3.2; and severe LBP was 4.6 +/- 3 (p = .0000). The disabled group was significantly different on both MMPI and Hopkins Checklist. The 20 disabled subjects had significant elevations of hypochondriasis (p = .0006) and hysteria (p = .005) when compared with nondisabled subjects with LBP. The mean score for disabled subjects on the Hopkins Checklist was 7.35 +/- 4.49, while the score was 4.17 +/- 3.15 (p = .0001) for the nondisabled subjects with LBP. In the general male population, patients with disabling LBP conditions form a distinctive subgroup comparable to those patients seen in selected LBP clinics.
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This is the second part of an extended review of the etiology and treatment of chronic back pain (CBP). The first paper dealt with somatic factors and interventions, this paper will examine psychological theories on the etiology of CBP and psychological treatments for CBP. Finally common problems of both the somatic and the psychological approaches will be discussed and suggestions for treatment and research will be made.
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This is the first part of an extended review of the etiology and treatment of chronic back pain (CBP). This paper will address the pathophysiology of CBP, the somatic conceptualizations that have been developed, and the treatment modalities that have been employed to alleviate the symptoms. The adequacy of the different models and treatments will be critically examined. The second paper in this set will examine psychological models and interventions. Common problems to both somatic and psychological approaches will be discussed at the close of the second paper.
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Leading contenders for the anatomical basis of spinal pain are the discs, zygapophyseal joints and spinal muscles. There are no scientific data, however, that sustain the belief that muscles may be a source of chronic pain. On the other hand, controlled studies have shown how common discogenic pain and zygapophyseal joint pain are. Cervical zygapophyseal joint pain accounts for for more than 50% of chronic neck pain after whiplash. Collectively, lumbar zygapophyseal joint pain, internal disk disruption and sacroiliac joint pain account for nearly 70% of chronic low back pain.
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The objective of the study was to determine the occurrence of low back pain and its relationship to back strength and physical activity in children. The study included 53 boys and 43 girls aged 10 to 19 years from a group of 116 children who had undergone isometric strength testing 4 years previously. No intervention was performed. Each child was asked five questions concerning low back pain. A questionnaire to quantify participation in athletic activities and manual labor was used as the basis for calculation of each child's activity level. Isometric back flexor and extensor strength were measured with the same method used 4 years previously. Statistical analyses were performed with appropriate correction for confounding factors. The frequency of low back pain and the relationship between low back pain and age, between low back pain and back strength, and between low back pain and physical activity were determined. There was a history of low back pain in 51%, and the frequency of low back pain in the past year was 35%. Eight percent of the children had been limited by low back pain, and 7% had seen a doctor for the pain. The first incident of low back pain occurred at a mean age of 12.3 years. The frequencies of a history of low back pain and of low back pain in the past year increased significantly with age (p = 0.02 and 0.01 respectively). Increased physical activity was significantly associated with a history of low back pain (p = 0.03), and increased back flexor strength was significantly associated with a history of low back pain and of low back pain in the past year (p = 0.03 and 0.008, respectively). The rate of low back flexor or strength over 4 years had a significantly positive association with the occurrence of low back pain in the past year (p = 0.008). Low back pain is common in children, and, in contrast to adults, low back pain in these children was more common with increased physical activity and stronger back flexors. We believe the main causes of low back pain in children are musculotendinous strains and ligamentous sprains.
Article
Cross-sectional data were collected in a postal questionnaire within the framework of a 5-year randomized, controlled, prospective, population-based study. To investigate to what extent associations differ or concur when correlates of low back pain are rested against various subdefinitions of low back pain. Numerous factors have been suspected to cause low back pain, but findings have not been constantly reproduced in epidemiologic studies. Data were collected on 748 people reporting nonspecific low back pain some time during the year preceding the survey. Six correlates of low back pain (age, sex, marital status, attitude to a healthy life-style, self-reported physical activity at work, and smoking) were cross-tabulated against nonspecific low back pain and against four subgroups of low back pain. There was only one statistically significant strong association between the potential risk indicators and the nonspecific definition of low back pain, but several emerged when the low back pain group was split into subgroups. Different subgroups of low back pain did, indeed, relate differently to the various correlates. It is necessary to define some clinically relevant subgroups of low back pain to accelerate the search for causal mechanisms.
Article
The hypothesis of reorganization of the primary somatosensory cortex in states of chronic pain was assessed in 10 low back pain patients and nine matched healthy controls. Intracutaneous electric stimuli were applied to the left back and index finger at a standard, a non-painful and a painful intensity. Magnetic fields were recorded by a 37-channel BTi biomagnetometer from the hemisphere contralateral to the site of stimulation. The power of the early evoked magnetic field (< 100 ms) elicited by painful stimulation of the painful back in very chronic patients was elevated relative to that elicited by painful back stimulation of healthy controls and showed a linear increase with chronicity (r = 0.74). The maximum activity elicited in primary somatosensory cortex was shifted more medially in the very chronic back pain subjects. These data suggest that chronic pain is accompanied by cortical reorganization and may serve an important function in the persistence of the pain experience.
Article
A randomized, controlled trial, test--retest design, with a 3-, 6-, and 30-month postal questionnaire follow-up. To determine the efficacy of a specific exercise intervention in the treatment of patients with chronic low back pain and a radiologic diagnosis of spondylolysis or spondylolisthesis. A recent focus in the physiotherapy management of patients with back pain has been the specific training of muscles surrounding the spine (deep abdominal muscles and lumbar multifidus), considered to provide dynamic stability and fine control to the lumbar spine. In no study have researchers evaluated the efficacy of this intervention in a population with chronic low back pain where the anatomic stability of the spine was compromised. Forty-four patients with this condition were assigned randomly to two treatment groups. The first group underwent a 10-week specific exercise treatment program involving the specific training of the deep abdominal muscles, with co-activation of the lumbar multifidus proximal to the pars defects. The activation of these muscles was incorporated into previously aggravating static postures and functional tasks. The control group underwent treatment as directed by their treating practitioner. After intervention, the specific exercise group showed a statistically significant reduction in pain intensity and functional disability levels, which was maintained at a 30-month follow-up. The control group showed no significant change in these parameters after intervention or at follow-up. A "specific exercise" treatment approach appears more effective than other commonly prescribed conservative treatment programs in patients with chronically symptomatic spondylolysis or spondylolisthesis.
Article
The management of peripheral neuropathic pain or nerve trunk pain relies upon accurate differential diagnosis. In part neurogenic pain has been attributed to increased activity in, as well as to abnormal processing of non-nociceptive input from, the nervi nervorum. For neurogenic pain to be identified as the dominant feature of a painful condition there should be evidence of increased nerve trunk mechanosensitivity from all aspects of the physical examination procedure. Consistent dysfunction should be identified on key active and passive movements, neural tissue provocation tests as well as nerve trunk palpation. A local cause for the neurogenic pain disorder should also be identified if the condition is to be treated by manual therapy. A treatment approach is presented which has been shown to have efficacy in the relief of pain and restoration of function in cervicobrachial pain disorders where there is evidence according to the outlined examination protocol of nerve trunk pain.
Article
A prospective study of personal risk factors for first-time low back pain. To construct and validate a multivariate model to predict low back pain. Various physical and psychological factors have been reported to increase the risk of low back pain, but conflicting results may be attributable to inaccurate "clinical" measures and to poorly validated statistical models. A total of 403 health care workers aged 18-40 years volunteered for the study. None had any history of "serious" back pain requiring medical attention or time off work. The volunteers completed the following questionnaires: the modified somatic perception questionnaire, the Zung depression scale, and the Health Locus of Control. Anthropometric factors were quantified using standard techniques. The 3Space Isotrak device (Polhemus, VT) was used to measure lumbar curvature and hip and lumbar spine mobility. Leg and back strength and back muscle fatiguability were measured in functional postures. Postal follow-up questionnaires, sent after 6, 12, 18, 24, 30, and 36 months, inquired about back pain, and multivariate logistic regression was used to identify risk factors at each follow-up. The response rate fell from 99% at 12 months to 90% at 36 months, at which time 90 volunteers reported "serious" back pain and 266 reported "any" back pain. The following were consistent predictors of serious back pain: reduced range of lumbar lateral bending, a long back, reduced lumbar lordosis, increased psychological distress, and previous nonserious low back pain. Only the latter three were consistent predictors of "any" back pain. Physical factors had the most influence in a sub-population of volunteers who were new to the job. Personal risk factors explained up to 12% of first-time low back pain.
Article
Low back pain (LBP) among children and adolescents has become the subject of an increasing amount of literature over the last 15 years. This topic, which was considered almost insignificant less than two decades ago, was the focus of a recent international meeting organised in Grenoble (France) in March 1999. This review paper is the result of an literature update search performed by members of three groups which have been active in this field for many years. Current epidemiological data on LBP is summarized as well as the role of the major risk factors according to studies published in the principal peer reviewed journals interested in the topic.
Article
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.
Article
The literature on psychological factors in neck and back pain was systematically searched and reviewed. To summarize current knowledge concerning the role of psychological variables in the etiology and development of neck and back pain. Recent conceptions of spinal pain, especially chronic back pain, have highlighted the role of psychological factors. Numerous studies subsequently have examined the effects of various psychological factors in neck and back pain. There is a need to review this material to ascertain what conclusions may be drawn. Medical and psychological databases and cross-referencing were used to locate 913 potentially relevant articles. A table of 37 studies was constructed, consisting only of studies with prospective designs to ensure quality. Each study was reviewed for the population studied, the psychological predictor variables, and the outcome. The available literature indicated a clear link between psychological variables and neck and back pain. The prospective studies indicated that psychological variables were related to the onset of pain, and to acute, subacute, and chronic pain. Stress, distress, or anxiety as well as mood and emotions, cognitive functioning, and pain behavior all were found to be significant factors. Personality factors produced mixed results. Although the level of evidence was low, abuse also was found to be a potentially significant factor. Psychological factors play a significant role not only in chronic pain, but also in the etiology of acute pain, particularly in the transition to chronic problems. Specific types of psychological variables emerge and may be important in distinct developmental time frames, also implying that assessment and intervention need to reflect these variables. Still, psychological factors account for only a portion of the variance, thereby highlighting the multidimensional view. Because the methodologic quality of the studies varied considerably, future research should focus on improving quality and addressing new questions such as the mechanism, the developmental time factor, and the relevance that these risk factors have for intervention.
Article
A very specific type of exercise has been devised which is proving to provide effective pain relief for chronic and recurrent back pain sufferers. The exercise approach focuses on retraining a precise co-contraction pattern of the deep trunk muscles, the transversus abdominis and lumbar multifidus. The approach is based on the knowledge of how muscles provide stability for the spine in normal situations. It has been further developed according to research evidence which has demonstrated dysfunction in the deep trunk muscles in patients with back pain. The mechanism for pain relief with this specific exercise approach is believed to be through enhanced stability of the lumbar spine segments.
Article
This paper provides evidence-based guidelines for the prescription of activity in the management of non-specific low back pain (NSLBP). The 62 clinical trials published between 1966 and 1997, identified by a search of the Medline and Cinahl databases, were reviewed to provide the basis for the guidelines. The available evidence suggests that physiotherapists should advise patients with acute and sub-acute NSLBP to avoid bed rest and to return to normal activity using time rather than pain as the guide to activity resumption. While structured exercise programs have not been shown to provide a benefit for acute NSLBP, there is strong evidence to support their use for patients with sub-acute and chronic NSLBP and in the prevention of NSLBP.
Article
This study investigated patterns of abdominal muscle recruitment during the abdominal drawing in manoeuvre in subjects with chronic low back pain (CLBP) and radiological diagnosis of spondylolysis or spondylolisthesis. Data were collected using surface electromyography from 12 physically active subjects with CLBP and 10 controls. The control subjects displayed an ability to preferentially activate internal oblique with minimal activation of upper rectus abdominis during the action of drawing in the abdominal wall. The group with CLBP were unable to achieve this. This finding may reflect the presence of neuromuscular dysfunction in this group. Further study is required to investigate if these findings are linked to the ability of patients with CLBP to provide dynamic stability of their lumbar spine.
Article
Review of advances in the primary care research on low back pain (LBP) from a unique international forum, and analysis of open-ended questionnaires from participants. LBP continues to be one of the most common and challenging problems in primary care. It is associated with enormous costs in terms of direct health care expenditures, and indirect work and disability-related losses. To ascertain the current status and state of the art regarding LBP in primary care. Four reviewers independently assessed the content and implications of presentations at the Fourth International Forum for Primary Care Research on LBP, pooled the data, and then augmented it with open-ended questionnaires completed by 35 participants. The Fourth Forum documented the field's emergent new paradigm-a transition from thinking about back pain as a biomedical "injury" to viewing LBP as a multifactorial biopsychosocial pain syndrome. The paradigm shift has occurred in the context of increased interest in evidence-based medicine regarding LBP in primary care. The Forum demonstrated the strides taken in moving from research and evidence gathering, through guidelines and policy formulations and finally to the dissemination and implementation imperative. There was an increasing confidence among the Forum researchers that LBP can be managed successfully in primary care settings through a combination of encouraging activity, reassurance, short-term symptom control, and alteration of inappropriate beliefs about the correlations of back pain with impairment and disability. There is also recognition that a wide range of international, evidence-based guidelines now exists that have very similar messages. The Fourth Forum reflected a major shift in the conceptualization of LBP in primary care and an increased emphasis on implementation and dissemination of LBP research findings and clinical guidelines. Although there is a wide array of challenges ahead, the Fourth Forum provided a clear message regarding the need to focus research energies on changing practitioner behavior.
Article
Manual therapy (MT-) is moving beyond its empirical origins and into an era of evidence-based practice. Mechanisms for the appearance of clinically observed symptoms and signs are beng incorporated into its clinical reasoning process. The recent, but well-documented phenomenon, central sensitization, is recognized as being one such mechanism. Anatomical, physiological, behavioural and clinical evidence demonstrate that, in addition to input from the periphery, central sensitization can be enhanced or maintained by supraspinal processes involving cognitions, attention ('focussing') and emotions. These forebrain products may, therefore, make a significant contribution to the symptoms and signs of common musculoskeletal presentations such as 'non-specific' back pain and fibromyalgia. The evidence can also be interpreted to provide MT with an acceptable role in the management of these patients.
Article
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.