Immediate Effects of a Single Session of Motor Skill Training on the Lumbar Movement Pattern During a Functional Activity in People With Low Back Pain: A Repeated-Measures Study

Person-specific characteristics of people with low back pain moderate the movement pattern within motor skill training and strength and flexibility exercise: Secondary analysis of a randomized clinical trial

People with low back pain (LBP) display an altered movement pattern during functional activities. Exercise-based treatments improve the altered pattern, but there is individual variability in the response to treatment. This study investigates the moderating effect of person-specific characteristics on a movement pattern at baseline and change over time in the pattern in people with chronic LBP who received motor skill training (MST) or strength and flexibility exercise (SFE). Kinematic data were collected at baseline, immediately post-treatment, and 6 months post-treatment. Lumbar contribution (LC) to total movement was used to quantify the magnitude of the altered movement pattern. Hierarchical linear modeling was used to explore the moderating effects of treatment group, age, sex, duration of LBP, and baseline LC on 1) baseline LC and 2) the change in LC over time. We found that person-specific characteristics moderated the change over time in LC within MST. Older people had a smaller change over time in LC and did not retain the improved pattern as well as younger people (β = 0.01, SE = 0.004, p < 0.01). People with greater baseline LC had a greater improvement in LC compared to people with less baseline LC (β = -0.07, SE = 0.01, p < 0.01).

Exploring booster session attendance, prescription, and outcomes in adults with chronic low back pain: Secondary analysis of a randomized clinical trial

Introduction

Booster sessions are a potential method for maintaining self-management behaviors and treatment effects in people with chronic low back pain (LBP). However, few studies have examined booster prescription or outcomes in people with LBP.

Objective

(1) Compare booster prescription for two exercise-based treatments for low back pain (LBP) in a randomized clinical trial (RCT) where the number of boosters prescribed was based on self-management program independence, (2) Determine if there are variables that predict who will require >1 booster, (3) Explore the effects of boosters on pain and function in people who required >1 booster.

Design

Secondary analysis of a RCT in which participants were randomized to motor skill training (MST), MST+Boosters (MST+B), strength and flexibility exercise (SFE), or SFE+B.

Setting

Academic research setting.

Participants

76 participants with chronic LBP assigned to receive boosters.

Interventions

This secondary analysis focuses only on the MST+B and SFE+B groups. Both groups received 6 visits of MST or SFE and six months later received up to 3 boosters. The number of boosters was based on self-management program independence at the first booster. Those who required >1 booster were not able to independently perform their program at the first booster.

Main Outcome Measures

Booster attendance and prescription, pain (Numeric Pain Rating Scale), function (modified Oswestry Disability Questionnaire).

Results

There was not a significant difference between MST+B and SFE+B in returning for the initial booster, χ 2 (1)=1.76, p=0.185. SFE+B were more likely to require >1 booster than MST+B; β =2.39, p <0.001. No participant-specific factors we examined were statistically related to needing >1 booster.

Conclusion

MST+B participants were less likely to require additional boosters. No additional participant-specific factors we examined were associated with needing additional boosters. Qualitatively, attending additional booster sessions did not appear to change pain or function in the current sample.

Assessing the Reliability and Validity of Inertial Measurement Units to Measure Three-Dimensional Spine and Hip Kinematics During Clinical Movement Tasks

Inertial measurement units (IMUs) provide benefits over the traditional optoelectronic motion capture (OMC) systems in measuring kinematics for the low back pain population. The reliability and validity of IMUs to quantify three-dimensional motion for multiple hip/spine segments have not been systematically evaluated. The purpose of this study was to determine the repeated-measures reliability and concurrent validity of an IMU system for measuring the three-dimensional spine/hip kinematics in six common movement assessments. Seventeen participants (32.3 (14.7) years; 11 female) performed two trials each of six range-of-motion assessments while fitted with four IMUs (T1/T2, T12/L1, L5/S1, and femur). The IMUs showed good-excellent reliability for most of the movements in the primary plane and poor-moderate reliability in the non-primary planes. The IMU and OMC systems showed generally good-excellent agreement in the primary plane and RMSE values between 3.03° and 15.75°. The removal of outliers based on the Bland-Altman analysis resulted in RMSE values between 2.44° and 10.30°. The system agreement in the non-primary planes was generally poor-moderate, and the RMSE values ranged from 2.19° to 45.88°. Anomalies in the proprietary sensor fusion algorithm or calibration may have contributed to the large RMSE values, highlighting the importance of assessing data for physiological relevance. The results suggest that these IMUs may be best suited for population-based studies measuring movement in the primary plane and point toward the need for the development of more robust approaches for broader implementation.

Preliminary Validity and Acceptability of Motion Tape for Measuring Low Back Movement: Mixed Methods Study

BACKGROUND

Low back pain (LBP) is a significant public health problem that can result in physical disability and financial burden for the individual and society. Physical therapy is effective for managing LBP and includes evaluation of posture and movement, interventions directed at modifying posture and movement, and prescription of exercises. However, physical therapists have limited tools for objective evaluation of low back posture and movement and monitoring of exercises, and this evaluation is limited to the time frame of a clinical encounter. There is a need for a valid tool that can be used to evaluate low back posture and movement and monitor exercises outside the clinic. To address this need, a fabric-based, wearable sensor, Motion Tape (MT), was developed and adapted for a low back use case. MT is a low-profile, disposable, self-adhesive, skin-strain sensor developed by spray coating piezoresistive graphene nanocomposites directly onto commercial kinesiology tape.

OBJECTIVE

The objectives of this study were to (1) validate MT for measuring low back posture and movement and (2) assess the acceptability of MT for users.

METHODS

A total of 10 participants without LBP were tested. A 3D optical motion capture system was used as a reference standard to measure low back kinematics. Retroreflective markers and a matrix of MTs were placed on the low back to measure kinematics (motion capture) and strain (MT) simultaneously during low back movements in the sagittal, frontal, and axial planes. Cross-correlation coefficients were calculated to evaluate the concurrent validity of MT strain in reference motion capture kinematics during each movement. The acceptability of MT was assessed using semistructured interviews conducted with each participant after laboratory testing. Interview data were analyzed using rapid qualitative analysis to identify themes and subthemes of user acceptability.

RESULTS

Visual inspection of concurrent MT strain and kinematics of the low back indicated that MT can distinguish between different movement directions. Cross-correlation coefficients between MT strain and motion capture kinematics ranged from -0.915 to 0.983, and the strength of the correlations varied across MT placements and low back movement directions. Regarding user acceptability, participants expressed enthusiasm toward MT and believed that it would be helpful for remote interventions for LBP but provided suggestions for improvement.

CONCLUSIONS

MT was able to distinguish between different low back movements, and most MTs demonstrated moderate to high correlation with motion capture kinematics. This preliminary laboratory validation of MT provides a basis for future device improvements, which will also involve testing in a free-living environment. Overall, users found MT acceptable for use in physical therapy for managing LBP.

Physical Therapists' Acceptance of a Wearable, Fabric-Based Sensor System (Motion Tape) for Use in Clinical Practice: Qualitative Focus Group Study

BACKGROUND

Low back pain (LBP) is a costly global health condition that affects individuals of all ages and genders. Physical therapy (PT) is a commonly used and effective intervention for the management of LBP and incorporates movement assessment and therapeutic exercise. A newly developed wearable, fabric-based sensor system, Motion Tape, uses novel sensing and data modeling to measure lumbar spine movements unobtrusively and thus offers potential benefits when used in conjunction with PT. However, physical therapists' acceptance of Motion Tape remains unexplored.

OBJECTIVE

The primary aim of this research study was to evaluate physical therapists' acceptance of Motion Tape to be used for the management of LBP. The secondary aim was to explore physical therapists' recommendations for future device development.

METHODS

Licensed physical therapists from the American Physical Therapy Association Academy of Leadership Technology Special Interest Group participated in this study. Overall, 2 focus groups (FGs; N=8) were conducted, in which participants were presented with Motion Tape samples and examples of app data output on a poster. Informed by the Technology Acceptance Model, we conducted semistructured FGs and explored the wearability, usefulness, and ease of use of and suggestions for improvements in Motion Tape for PT management of LBP. FG data were transcribed and analyzed using rapid qualitative analysis.

RESULTS

Regarding wearability, participants perceived that Motion Tape would be able to adhere for several days, with some variability owing to external factors. Feedback was positive for the low-profile and universal fit, but discomfort owing to wires and potential friction with clothing was of concern. Other concerns included difficulty with self-application and potential skin sensitivity. Regarding usefulness, participants expressed that Motion Tape would enhance the efficiency and specificity of assessments and treatment. Regarding ease of use, participants stated that the app would be easy, but data management and challenges with interpretation were of concern. Physical therapists provided several recommendations for future design improvements including having a wireless system or removable wires, customizable sizes for the tape, and output including range of motion data and summary graphs and adding app features that consider patient input and context.

CONCLUSIONS

Several themes related to Motion Tape's wearability, usefulness, and ease of use were identified. Overall, physical therapists expressed acceptance of Motion Tape's potential for assessing and monitoring low back posture and movement, both within and outside clinical settings. Participants expressed that Motion Tape would be a valuable tool for the personalized treatment of LBP but highlighted several future improvements needed for Motion Tape to be used in practice.

Neuromuscular exercise and counseling for treating recurrent low back pain in female healthcare workers-Findings from a 24-month follow-up study of a randomized controlled trial

BACKGROUND

Female healthcare workers have a high prevalence of low back pain (LBP)-related sickness absence. Here, we report findings of a 24-month follow-up of a previously published 6-month randomized controlled trial (RCT).

METHODS

By adopting an RCT with 6 months of intervention and follow-up at 6, 12, and 24 months, we assessed the maintenance of changes in the effectiveness (LBP and fear of pain) of the interventions (neuromuscular exercise [NME], back-care counseling, both combined) using a generalized linear mixed model adjusted for baseline covariates. The incremental cost-effectiveness ratio was calculated in terms of quality-adjusted life years (QALY). A bootstrap technique was used to estimate the uncertainty around a cost-effectiveness acceptability curve.

RESULTS

Of the 219 females, 71% had data at 24 months. Between 6 and 24 months, LBP intensity (primary outcome) remained low in all intervention arms (-20% to -48%) compared to the control (-10% to -16%). Pain interfering with work remained low in the combined and exercise arms for up to 24 months. At 24 months, the total costs were lowest in the combined arm (€484 vs. €613-948, p < 0.001), as were the number of back-related sickness absence days (0.16 vs. 1.14-3.26, p = 0.003). The analysis indicated a 95% probability of the combined arm to be cost-effective per QALY gained at €1120.

CONCLUSIONS

Six months of weekly NME combined with four counseling sessions was cost-effective for treating LBP and the effect was maintained over 24 months.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01465698, 7/11/2011, prospective.

Treatment preference changes after exposure to treatment in adults with chronic low back pain

BACKGROUND

Patients' pretreatment preferences can influence outcomes of nonpharmacologic treatments for musculoskeletal pain. Less is known about how patients' treatment preferences change following exposure to treatment.

OBJECTIVE

To examine the effect of exposure to treatment and change in disability and pain on treatment preference ratings of two exercise-based treatments for people with chronic low back pain (LBP).

DESIGN

Secondary analysis of a subsample of participants from a randomized clinical trial.

SETTING

Academic research setting.

PARTICIPANTS

Individuals with chronic LBP (n = 83).

INTERVENTIONS

6 weekly sessions of motor skill training (MST) or strength and flexibility exercise (SFE).

MAIN OUTCOME MEASURES

Prior to treatment, participants completed a treatment preference assessment measure (TPA) describing MST and SFE. Participants rated four attributes (effectiveness, acceptability/logicality, suitability/appropriateness, convenience) of each treatment on a 5-point Likert scale (0-4) with higher scores indicating higher ratings. An overall preference rating was calculated as the mean of the attribute ratings. The TPA was administered 12 months post treatment to reassess participants' ratings of the treatment they received.

RESULTS

Participants who received MST rated their preference for MST higher 12 months post treatment and participants who received SFE rated their preference for SFE lower. Smaller improvements (to worsening) in pain were associated with a reduction in preference ratings in the SFE group, whereas the MST group generally increased their ratings regardless of pain. Changes in disability were not related to changes in preference ratings.

CONCLUSIONS

Participants changed their preference ratings of two exercise-based treatments for LBP after exposure to the treatment. Participants who received the less familiar MST viewed this treatment more favorably 12 months post treatment, and this change was less contingent on changes in disability/pain than for participants in the SFE group. Assessing preference ratings at various times during treatment is crucial to understand a person's preference for and perceptions of a treatment.

Does intra-lumbar flexion during lifting differ in manual workers with and without a history of low back pain? A cross-sectional laboratory study

Advice to limit or avoid a flexed lumbar curvature during lifting is widely promoted to reduce the risk of low back pain (LBP), yet there is very limited evidence to support this relationship. To provide higher quality evidence this study compared intra-lumbar flexion in manual workers with (n = 21) and without a history of LBP (n = 21) during a repeated lifting task. In contrast to common expectations, the LBP group demonstrated less peak absolute intra-lumbar flexion during lifting than the noLBP group [adjusted difference -3.7° (95%CI -6.9 to -0.6)]. The LBP group was also further from the end of range intra-lumbar flexion and did not use more intra-lumbar range of motion during any lift condition (both symmetrical and asymmetrical lifts and different box loads). Peak absolute intra-lumbar flexion was more variable in the LBP group during lifting and both groups increased their peak absolute intra-lumbar flexion over the lift repetitions. This high-quality capture of intra-lumbar spine flexion during repeated lifting in a clinically relevant cohort questions dominant safe lifting advice.Practitioner summary: Lifting remains a common trigger for low back pain (LBP). This study demonstrated that people with LBP, lift with less intra-lumbar flexion than those without LBP. Providing the best quality in-vivo laboratory evidence, that greater intra-lumbar flexion is not associated with LBP in manual workers, raising questions about lifting advice.

Effects of combined hip exercise and passive stretching on muscle stiffness, pain perception and painrelated disability, and physical function in older adults with low back pain

[Purpose] This study aimed to examine the effects of combined hip exercise and passive stretching as a novel treatment method for low back pain (LBP) in older adults.[Methods] Altogether, 20 Koreans with LBP aged 60–79 years (67.3 ± 5.92 years) were randomly assigned to undertake combined exercise (CE; n = 10) or lumbar stabilization exercise (LSE; n = 10). All participants performed their respective exercise program for 25–30 min with an OMNI scale of 6–8 for 8 weeks, three times a week. Body composition, muscle stiffness, pain-visual analog scale (P-VAS), Oswestry disability index, and physical function were evaluated before and after the exercise intervention.[Results] The CE group demonstrated greater improvements in lean body mass (<i>η²</i> = 0.402, <i>p</i> = 0.003) and percent body fat (<i>η²</i> = 0.222, <i>p</i> = 0.036) than the LSE group. Both groups demonstrated significant improvements in muscle stiffness, P-VAS scores, and Oswestry disability index scores, although no significant differences were observed between the interventions. All physical function parameters demonstrated a significant improvement in both groups, and the CE group demonstrated greater improvement in the YMCA sit-and-reach (<i>η²</i> = 0.338, <i>p</i> = 0.007) and straight leg raise tests (<i>η²</i> = 0.283, p = 0.016) than the LSE group.[Conclusion] CE is comparable to LSE as an effective and successful exercise intervention that reduces muscle stiffness and P-VAS scores. Moreover, CE is more effective than LSE in enhancing the physical function of older adults with LBP.

Participants with mildly-disabling chronic neck pain perform differently during explicit compared to implicit motor learning of a reaching task

Chronic musculoskeletal (CMSK) pain associated with musculoskeletal disorders like low back pain or neck pain are the leading causes of disability. While CMSK pain has the potential to negatively influence motor learning, there is limited research to understand the impact of CMSK on motor learning. In order to examine differences in motor learning between individuals with and without CMSK we modified a serial reaction time task to assess motor learning of a repetitive reaching task. The paradigm was used to assess both explicit and implicit motor learning. In a cross-sectional study design, seventeen participants with chronic neck pain (CNP) (5 males) and 21 controls (8 males) were recruited. In addition, physical, cognitive, sensorimotor, disability and pain assessments were used to examine differences between individuals with and without CNP. All participants with CNP were categorized as having mild disability. There was no difference in cognitive assessments and minimal differences in physical measures between groups. Examining motor learning, groups with and without CNP demonstrated similar outcomes in both explicit and implicit motor learning. There was one notable performance difference between groups in the reaching task, the group with CNP demonstrated slower reaching movements outward and inward during blocks without explicit information. This may suggest a cautious approach to movement with reduced explicit information. Findings from this study provide insight on motor learning in individuals with mildly-disabling CNP, further research is necessary to examine how instruction can impact peak performance in people with CMSK pain.

Linking Pain and Motor Control: Conceptualization of Movement Deficits in Patients With Painful Conditions

When people experience or expect pain, they move differently. Pain-altered movement strategies, collectively described here as pain-related movement dysfunction (PRMD), may persist well after pain resolves and, ultimately, may result in altered kinematics and kinetics, future reinjury, and disability. Although PRMD may manifest as abnormal movements that are often evident in clinical assessment, the underlying mechanisms are complex, engaging sensory-perceptual, cognitive, psychological, and motor processes. Motor control theories provide a conceptual framework to determine, assess, and target processes that contribute to normal and abnormal movement and thus are important for physical therapy and rehabilitation practice. Contemporary understanding of motor control has evolved from reflex-based understanding to a more complex task-dependent interaction between cognitive and motor systems, each with distinct neuroanatomic substrates. Though experts have recognized the importance of motor control in the management of painful conditions, there is no comprehensive framework that explicates the processes engaged in the control of goal-directed actions, particularly in the presence of pain. This Perspective outlines sensory-perceptual, cognitive, psychological, and motor processes in the contemporary model of motor control, describing the neural substrates underlying each process and highlighting how pain and anticipation of pain influence motor control processes and consequently contribute to PRMD. Finally, potential lines of future inquiry-grounded in the contemporary model of motor control-are outlined to advance understanding and improve the assessment and treatment of PRMD.

IMPACT

This Perspective proposes that approaching PRMD from a contemporary motor control perspective will uncover key mechanisms, identify treatment targets, inform assessments, and innovate treatments across sensory-perceptual, cognitive, and motor domains, all of which have the potential to improve movement and functional outcomes in patients with painful conditions.

Opioid use and social disadvantage in patients with chronic musculoskeletal pain

BACKGROUND

Historically, marginalized patients were prescribed less opioid medication than affluent, white patients. However, because of persistent differential access to nonopioid pain treatments, this direction of disparity in opioid prescribing may have reversed.

OBJECTIVE

To compare social disadvantage and health in patients with chronic pain who were managed with versus without chronic opioid therapy. It was hypothesized that patients routinely prescribed opioids would be more likely to live in socially disadvantaged communities and report worse health.

DESIGN

Cross-sectional analysis of a retrospective cohort defined from medical records from 2000 to 2019.

SETTING

Single tertiary safety net medical center.

PATIENTS

Adult patients with chronic musculoskeletal pain who were managed longitudinally by a physiatric group practice from at least 2011 to 2015 (n = 1173), subgrouped by chronic (≥4 years) adherent opioid usage (n = 356) versus no chronic opioid usage (n = 817).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The primary outcome was the unadjusted between-group difference in social disadvantage, defined by living in the worst national quartile of the Area Deprivation Index (ADI). An adjusted effect size was also calculated using logistic regression, with age, sex, race, and Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Physical Function scores as covariates. Secondary outcomes included adjusted differences in health by chronic opioid use (measured by PROMIS).

RESULTS

Patients managed with chronic opioid therapy were more likely to live in a zip code within the most socially disadvantaged national quartile (34.9%; 95% confidence interval [CI] 29.9-39.9%; vs. 24.9%; 95% CI 21.9-28.0%; P < .001), and social disadvantage was independently associated with chronic opioid use (odds ratio [OR] 1.01 per ADI percentile [1.01-1.02]). Opioid use was also associated with meaningfully worse PROMIS Depression (3.8 points [2.4-5.1]), Anxiety (3.0 [1.4-4.5]), and Pain Interference (2.6 [1.7-3.5]) scores.

CONCLUSIONS

Patients prescribed chronic opioid treatment were more likely to live in socially disadvantaged neighborhoods, and chronic opioid use was independently associated with worse behavioral health. Improving access to multidisciplinary, nonopioid treatments for chronic pain may be key to successfully overcoming the opioid crisis.

Motor skill training versus strength and flexibility exercise in people with chronic low back pain: Preplanned analysis of effects on kinematics during a functional activity

BACKGROUND

People with chronic low back pain display the altered movement pattern where the lumbar spine moves more readily into its available range of motion relative to other joints. A logical approach to treatment, therefore, would be to improve this pattern during functional activities.

METHODS

154 participants were randomized to receive 6 weeks of motor skill training or strength and flexibility exercise. Participants in the motor skill training group received person-specific training to modify their altered movement pattern during functional activities. Participants in the strength and flexibility group received exercises for trunk strength and trunk and lower-limb flexibility. At baseline, post-treatment and 6-months after treatment participants performed a test of picking up an object using their preferred pattern. Three-dimensional marker co-ordinate data were collected. A mixed-model repeated measures analysis of variance was used to examine the treatment group and time effects.

FINDINGS

Motor skill training: Baseline early excursion values [mean (confidence interval)] were as follows: knee = 11.1°(8.0,4.1), hip = 21.2°(19.2,23.1), lumbar = 11.3°(10.4,12.3). From baseline to post-treatment significant improvements in early excursion included: knee = +18.6°(15.4,21.8), hip = +10.8°(8.8,12.8), and lumbar = -2.0°(-0.1,-4.0). There were no significant changes from post-treatment to 6-month follow-up. Strength and flexibility exercise: Baseline early excursion values were as follows: knee = 8.9°(5.8,11.9), hip = 20.8°(18.9,22.8), and lumbar = 11.2°(10.3,12.2) early excursion. There were no significant changes for knee, hip, and lumbar early excursion.

INTERPRETATION

Motor skill training was more effective than strength and flexibility exercise at changing and maintaining change to the altered movement pattern during a functional activity test of picking up an object.

Task-specific movement training improves kinematics and pain during the Y-balance test and hip muscle strength in females with patellofemoral pain

OBJECTIVES

Task-specific movement training is a proposed intervention for patellofemoral pain aimed to optimise movement during daily tasks. Focused, progressive task practice emphasising optimal limb alignment may yield improvements in performance-based function and hip muscle strength, and transfer learnt movement patterns to untrained tasks. The purpose of this study was to determine if task-specific movement training improves performance-based function (composite score, movement, pain during movement) in an untrained task. Our secondary purpose was to test whether hip muscle strength improved following the movement training intervention.

METHODS

This study was a secondary analysis of a prospective, non-randomised, within-group, double-baseline study. Twenty-three females with patellofemoral pain underwent task-specific movement training two times/week for 6 weeks. Outcomes were collected at three time points: enrolment (baseline), 6 weeks (preintervention) and 12 weeks (postintervention). A repeated measures analysis of variance tested whether the change during the intervention phase was greater than the change during the control phase. Y-balance composite score, hip and knee kinematics and pain during the Y-balance test were primary outcome measures; strength of the hip lateral rotator, abductor and extensor muscles was a secondary outcome measure.

RESULTS

The change in composite score for the Y-balance test was not statistically significantly different between the intervention and control phases (p=0.16). The change during the intervention phase exceeded the change during the control phase for hip and knee kinematics and pain during the Y-balance test, with all variables improving (p<0.0001). The change during the intervention phase was greater than the control phase for hip muscle strength, with all variables improving (p<0.04).

CONCLUSION

Although the Y-balance test composite score did not improve, performance-based function during an untrained task, measured by movement and pain during the test, improved following task-specific movement training. Hip muscle strength improved, despite no focused muscle strengthening.

LEVEL OF EVIDENCE

Level II.

To Flex or Not to Flex? Is There a Relationship Between Lumbar Spine Flexion During Lifting and Low Back Pain? A Systematic Review With Meta-analysis

OBJECTIVE

To evaluate whether lumbar spine flexion during lifting is a risk factor for low back pain (LBP) onset/persistence or a differentiator of people with and without LBP.

DESIGN

Etiology systematic review with meta-analysis.

LITERATURE SEARCH

Database search of ProQuest, CINAHL, MEDLINE, and Embase up to August 21, 2018.

STUDY SELECTION CRITERIA

We included peer-reviewed articles that investigated whether lumbar spine position during lifting was a risk factor for LBP onset or persistence or a differentiator of people with and without LBP.

DATA SYNTHESIS

Lifting-task comparison data were tabulated and summarized. The meta-analysis calculated an n-weighted pooled mean ± SD of the results in the LBP and no-LBP groups. If a study contained multiple comparisons (ie, different lifting tasks that used various weights or directions), then only 1 result from that study was included in the meta-analysis.

RESULTS

Four studies (1 longitudinal study and 3 cross-sectional studies across 5 articles) included in meta-analysis measured lumbar flexion with intralumbar angles and found no difference in peak lumbar spine flexion when lifting (1.5°; 95% confidence interval [CI]: -0.7°, 3.7°; P = .19 for the longitudinal study and -0.9°; 95% CI: -2.5°, 0.7°; P = .29 for the cross-sectional studies). Seven cross-sectional studies measured lumbar flexion with thoracopelvic angles and found that people with LBP lifted with 6.0° less lumbar flexion than people without LBP (95% CI: -11.2°, -0.9°; P = .02). Most (9/11) studies reported no significant between-group differences in lumbar flexion during lifting. The included studies were of low quality.

CONCLUSION

There was low-quality evidence that greater lumbar spine flexion during lifting was not a risk factor for LBP onset/persistence or a differentiator of people with and without LBP. J Orthop Sports Phys Ther 2020;50(3):121-130. Epub 28 Nov 2019. doi:10.2519/jospt.2020.9218.

Modified Outpatient Physical Therapy Improvement in Movement Assessment Log (mOPTIMAL): A Responsive and Reliable Tool for Patients with Non-Operative Shoulder Pain

BACKGROUND

Medicare regulations require that physical therapists report functional limitations and severity modifiers utilizing a claims-based data collection tool. The Modified Outpatient Physical Therapy Improvement in Movement Assessment Log (mOPTIMAL) captures key constructs about patient confidence and difficulty but has not been evaluated for responsiveness/ reliability during a routine clinical encounter with patients who have shoulder pathology. The purposes of this retrospective study are to 1) explore if mOPTIMAL changes after a single session with a physical therapist, and 2) determine if the tool is reliable among people with non-operative shoulder pain.

METHODS

We included 106 individuals (58% female; mean age 45.8; range: 18-94 yrs.) with "non-operative" shoulder pathology who were seen in outpatient physical therapy from 2011 to 2012. Subjects completed a mOPTIMAL survey and a pain scale before and immediately after the initial physical therapy visit. The mOPTIMAL is a patient-centered instrument that assesses how much "Difficulty" and "Confidence" a client has in performing a battery of functional tasks. T-tests, Cronbach's Alpha, and Intra-class Correlations were used to assess responsiveness, internal consistency, and reliability, respectively.

RESULTS

After a single visit, participants reported improved Confidence with sleeping, dressing/ bathing, throwing, carrying, and lifting (adjusted for ceiling effects; p<0.002) but no change in pain. Cronbach's Alpha and Intra-class Correlations were excellent (0.821-0.923; 0.967, respectively).

CONCLUSIONS

mOPTIMAL is a reliable and responsive tool with excellent internal consistency. This observational study revealed that patient Confidence may change independent of Pain after a single physical therapy visit. Taken together, the mOPTIMAL appears to be an excellent tool to report severity modifiers in compliance with Medicare regulations.Level of Evidence: IV.

Examination of the Lumbar Movement Pattern during a Clinical Test and a Functional Activity Test in People with and without Low Back Pain

BACKGROUND

It is assumed that the lumbar movement pattern observed during a clinical test is representative of the movement pattern used during a functional activity. Very little is known about how the lumbar movement pattern during a clinical test is associated with the lumbar movement pattern during a functional activity and how the lumbar movement pattern is associated with functional limitation.

OBJECTIVE

The purpose was to examine the lumbar movement pattern during a clinical test and a functional activity test in people with and people without low back pain (LBP), and the relationship of lumbar motion to LBP-related functional limitation.

DESIGN

Observational study.

PARTICIPANTS

16 back-healthy adults and 32 people with chronic LBP.

METHODS

Participants performed a standardized clinical test of forward bending and a functional activity test of picking up an object.

MAIN OUTCOME MEASUREMENTS

Maximal lumbar excursion and lumbar excursion at 0% to 50% and 50% to 100% of movement time were examined.

RESULTS

Significant associations were present between the two movement tests for both back-healthy people and people with LBP (r = 0.47-0.73). In people with LBP the amount of lumbar motion in the 0% to 50% of movement time interval for both tests was significantly associated with functional limitation (r = 0.43-0.62).

CONCLUSION

Lumbar movement patterns were similar between the two tests, and lumbar motion early in the movement of a functional test was related to self-report of functional limitation.

LEVEL OF EVIDENCE

III.

Neuromuscular exercise reduces low back pain intensity and improves physical functioning in nursing duties among female healthcare workers; secondary analysis of a randomised controlled trial

Background

Low back pain (LBP) is common among healthcare workers, whose work is physically strenuous and thus demands certain levels of physical fitness and spinal control. Exercise is the most frequently recommended treatment for LBP. However, exercise interventions targeted at sub-acute or recurrent patients are scarce compared to those targeted at chronic LBP patients. Our objective was to examine the effects of 6 months of neuromuscular exercise on pain, lumbar movement control, fitness, and work-related factors at 6- and 12-months’ follow-up among female healthcare personnel with sub-acute or recurrent low back pain (LBP) and physically demanding work.

Methods

A total of 219 healthcare workers aged 30–55 years with non-specific LBP were originally allocated to four groups (exercise, counselling, combined exercise and counselling, control). The present study is a secondary analysis comparing exercisers (n = 110) vs non-exercisers (n = 109). Exercise was performed twice a week (60 min) in three progressive stages focusing on controlling the neutral spine posture. The primary outcome was intensity of LBP. Secondary outcomes included pain interfering with work, lumbar movement control, fitness components, and work-related measurements. Between-group differences were analysed with a generalised linear mixed model according to the intention-to-treat principle. Per-protocol analysis compared the more exercised to the less exercised and non-exercisers.

Results

The mean exercise attendance was 26.3 (SD 12.2) of targeted 48 sessions over 24 weeks, 53% exercising 1–2 times a week, with 80% (n = 176) and 72% (n = 157) participating in 6- and in 12-month follow-up measurements, respectively. The exercise intervention reduced pain (p = 0.047), and pain interfering with work (p = 0.046); improved lumbar movement control (p = 0.042), abdominal strength (p = 0.033) and physical functioning in heavy nursing duties (p = 0.007); but had no effect on other fitness and work-related measurements when compared to not exercising. High exercise compliance resulted in less pain and better lumbar movement control and walking test results.

Conclusion

Neuromuscular exercise was effective in reducing pain and improving lumbar movement control, abdominal strength, and physical functioning in nursing duties compared to not exercising.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2678-x) contains supplementary material, which is available to authorized users.

Can Biomechanics Research Lead to More Effective Treatment of Low Back Pain? A Point-Counterpoint Debate

SYNOPSIS

Although biomechanics plays a role in the development and perhaps the persistent or recurrent nature of low back pain (LBP), whether biomechanics alone can provide the basis for intervention is debated. Biomechanics, which refers to the mechanics of the body, including its neuromuscular control, has been studied extensively in LBP. But, can gains be made in understanding LBP by research focused on this component of biology in the multifactorial biopsychosocial problem of LBP? This commentary considers whether biomechanics research has the potential to advance treatment of LBP, and how likely it is that this research will lead to better treatment strategies. A point-counterpoint format is taken to present both sides of the argument. First, the challenges faced by an approach that considers biomechanics in isolation are presented. Next, we describe 3 models that place substantial emphasis on biomechanical factors. Finally, reactions to each point are presented as a foundation for further research and clinical practice to progress understanding of the place for biomechanics in guiding treatment of LBP. J Orthop Sports Phys Ther 2019;49(6):425-436. Epub 15 May 2019. doi:10.2519/jospt.2019.8825.

Convergence and Divergence of Exercise-Based Approaches That Incorporate Motor Control for the Management of Low Back Pain

Many approaches for low back pain (LBP) management focus on modifying motor control, which refers to motor, sensory, and central processes for control of posture and movement. A common assumption across approaches is that the way an individual loads the spine by typical postures, movements, and muscle activation strategies contributes to LBP symptom onset, persistence, and recovery. However, there are also divergent features from one approach to another. This commentary presents key principles of 4 clinical physical therapy approaches, including how each incorporates motor control in LBP management, the convergence and divergence of these approaches, and how they interface with medical LBP management. The approaches considered are movement system impairment syndromes of the lumbar spine, Mechanical Diagnosis and Therapy, motor control training, and the integrated systems model. These were selected to represent the diversity of applications, including approaches using motor control as a central or an adjunct feature, and approaches that are evidence based or evidence informed. This identification of areas of convergence and divergence of approaches is designed to clarify the key aspects of each approach and thereby serve as a guide for the clinician and to provide a platform for considering a hybrid approach tailored to the individual patient. J Orthop Sports Phys Ther 2019;49(6):437-452. Epub 15 May 2019. doi:10.2519/jospt.2019.8451.