Analysis of Motor Control in Patients With Low Back Pain: A Key to Personalized Care?

Implications for fall efficacy strategies on center of pressure and center of gravity sway distances in adults with chronic low back pain

BACKGROUND

Although chronic low back pain (LBP) is a complex condition often associated with altered motor control and compensatory postural adjustments, existing literature provides inconsistent reports on the underlying control mechanisms for maintaining balance.

PURPOSE

This study aimed to compare differences in sway distances between the center of pressure (COP) and the center of gravity (COG), while considering limb dominance, in adults with and without LBP.

METHODS

There were 26 subjects with LBP and 39 control subjects who performed three repeated unilateral standing tasks on a force platform. Outcome measures included the sway distances between COP and COG in the anteroposterior (AP) and mediolateral (ML) directions, as well as the results of the fall efficacy scale (FES).

RESULTS

A significant group interaction was demonstrated on limb dominance and direction for the sway distance (F = 5.46, p = 0.02). Specifically, the third trial in the ML direction while standing on the dominant limb indicated a significant difference in COP-COG sway distance (t = -2.30, p = 0.01). When FES scores were used as a covariate, a significant three-way interaction (dominance x direction x trial) was found (F = 4.06, p = 0.04).

CONCLUSION

Although no significant group interaction was observed for dominance, direction, and trial, the LBP group demonstrated an ability to leverage fall efficacy following repeated trials to reduce ML balance deficits. Clinicians should consider neuromuscular control and limb dominance when developing fall efficacy strategies for postural adaptations in adults with LBP.

Functional vs. dual-task training effects on trunk muscle function and functional fitness in older women with and without chronic low back pain: A randomized clinical trial

INTRODUCTION

Non-specific chronic low back pain (CLBP) predominantly affects women aged 40-80 years. Physical exercise is a primary treatment form, with functional training (FT) and dual-task training (DT) emerging as potential modalities due to their distinct characteristics. However, limited information exists regarding the effects of these exercise modalities on CLBP.

OBJECTIVE

To compare the FT and DT effects on trunk function and functional fitness in CLBP older women.

METHODOLOGY

This was a randomized clinical trial with two training groups (FT and DT) and CLBP and non-CLBP individuals. We assessed the trunk stability, maximum isometric strength, endurance of trunk muscles, and functional fitness before and after 16 weeks of training RESULTS: We found only time effects for circular stability and instability (p <.001), flexors (p =.006), and extensors endurance (p <.001). For the lateral flexors, there was an average reduction of 17.3 units in lateral flexor endurance in the FT compared to the DT in CLBP individuals. For the strength of the flexor, CLBP individuals exhibited an increase of 69.3 units compared to non-CLBP. For the strength of extensors, CLBP individuals showed a decrease of 75.1 units compared to non-CLBP individuals. We identified a time effect for all functional fitness measures (p <.050) CONCLUSION: FT and DT increase trunk stability, maximum isometric strength, and endurance of trunk muscles, besides the functional fitness of CLBP older women SIGNIFICANCE: Professionals can choose either training type, as there are no differences in the initial 16 weeks of intervention.

Validation of proprioception measures of the lumbar spine

BACKGROUND

To better personalize treatment and monitor recovery of individuals with low back pain, objective tests of sensorimotor functions, such as lumbar proprioception, must be selected based on their reliability and validity. The primary objective of this study was to test the concurrent validity of three measures of lumbar proprioception.

METHODS

Thirty-one participants performed three lumbar proprioception tests (motion perception threshold, active and passive joint positioning sense), a whole-body mobility and balance (time up-and-go) and two trunk-specific postural control (threshold of stability and sensor-based sway measures) tests.

RESULTS

Only the motion perception threshold proprioception test showed some validity, correlating with the trunk-specific postural control tests [r range (positive values): 0.37 to 0.60]. The three lumbar proprioception measures were not correlated to each other. The threshold of stability measure was correlated with the time up-and-go (r = 0.37) and trunk-specific (sensor-based sway measures) postural control [r range (positive values): 0.48 to 0.77] tests.

CONCLUSION

The present study generated three original findings. Only the motion perception threshold proprioception test demonstrated its concurrent validity. In fact, the three lumbar proprioception tests performed in the present study were not correlated to each other, thus assessing different constructs. Finally, the threshold of stability protocol was validated against other tests. These findings will help in selecting the most appropriate lumbar proprioception measures to study the effects of exercise treatments in patients with back pain.

Kinematic patterns in performing trunk flexion tasks influenced by various mechanical optimization targets: A simulation study

BACKGROUND

Low back pain is the most prevalent and disabling condition worldwide, with a high recurrence rate in the general adult population.

METHODS

A set of open-sourced trunk musculoskeletal models was used to investigate trunk flexion kinematics under different motor control strategies, including minimizing shearing or compressive loads at the L4/L5 or L5/S1 level.

FINDINGS

A control strategy that minimizes the load on the lower lumbar intervertebral disc can result in two kinematic patterns-the "restricted lumbar spine" and the "overflexed lumbar spine"-in performing the trunk flexion task. The "restricted" pattern can reduce the overall load on the lower lumbar levels, whereas the "overflexed" pattern can reduce the shearing force only at the L4/L5 level and increase the compressive and shearing forces at the L5/S1 level and the compressive force at the L4/L5 level.

INTERPRETATION

This study investigated the relationships between specific trunk kinematics in patients with low back pain and lumbar intervertebral loading via musculoskeletal modelling and simulation. The results provide insight into individualized treatment for patients with low back pain.

The clinical utility of the prone hip extension test in the diagnosis of motor control impairments associated with low back pain: A cross-sectional study using motion capture and electromyography

BACKGROUND

The prone hip extension test is used as a clinical tool to diagnose specific motor control impairments that have been identified in individuals with chronic low back pain. However, conventional protocols for performing the test are subjective and lack evidence for their effectiveness. The objective of the current study was to quantify lumbopelvic motion and muscle activation during this test and identify which motor control patterns best distinguish individuals with low back pain from asymptomatic controls.

METHODS

18 individuals with sub-acute or chronic low back pain and 32 asymptomatic controls performed the prone hip extension test while a 3D motion capture system measured lumbar and pelvic movement patterns and an electromyography system measured the muscle activation patterns of the paraspinal, gluteus maximus, and hamstring muscles. A three-stage statistical analysis was performed, the final stage being a stepwise logistic regression analysis aimed at identifying the movement and muscle activation pattern variables that best distinguished the two groups.

FINDINGS

The final regression model included three lumbar kinematic variables and several electromyographic amplitude variables for the gluteus maximus and hamstring muscles during right-sided prone hip extension. The final model correctly classified 86.7 % of the control group and 83.3 % of the low back pain group.

INTERPRETATION

The subject of asymmetrical gluteus maximus and hamstring muscle activation appears to be a potentially interesting area for future research on the utility of the prone hip extension test as a clinical tool in diagnosing motor control impairments associated with low back pain.

Tactile acuity and active joint repositioning sense in individuals with and without chronic low back pain: a cross-sectional study

BACKGROUND

Sensorimotor dysfunction, as measured by tactile acuity and active joint repositioning, has been identified as a contributing factor of chronic low back pain (CLBP). Existing research suggests that further research is necessary to improve the characterization of sensorimotor perception in patients with CLBP.

OBJECTIVES

The main aim is to investigate whether tactile acuity and repositioning errors differ between individuals with CLBP and controls without CLBP. A secondary aim was to investigate the association between age, body mass index (BMI) and physical activity, and tactile acuity and repositioning sense.

METHODS

Cross-sectional study. Sixty-eight participants (36 with, 32 without CLBP) were examined. Two-Point Discrimination (TPD) test (four measures: horizontal and vertical run, left and right side) and Active Joint Reposition Sense (AJRS) test (2 directions: to flexion and to extension) were used.

RESULTS

No differences were found for TPD (right horizontal run: p = .069; left horizontal run: p = .066; right vertical run: p = .933; left vertical run: p = .285) or AJRS (flexion: p = .792; extension: p = .956) between participants with and without CLBP. Older subjects had significantly worse tactile acuity (3 sites, p = .018, p = .004, p = .041) and worse repositioning sense (2 directions, p = .026, p = .040,) than younger subjects. Individuals with BMI ≥ 25 had significantly worse TPD compared to individuals with normal weight (2 sites, p = .028, p = .020).

CONCLUSIONS

Individuals with CLBP did not have impaired tactile and repositioning accuracy when compared to controls without CLBP. Future studies comparing sensorimotor performance should consider age and BMI as potential confounding factors.

Precision Rehabilitation After Neurostimulation Implantation for Multifidus Dysfunction in Nociceptive Mechanical Chronic Low Back Pain

Chronic low back pain (CLBP) is a debilitating, painful, and costly condition. Implantable neuromuscular electrical stimulation targeting the multifidus musculature is growing as a non-pharmacologic option for patients with recalcitrant nociceptive mechanical CLBP who have failed conservative treatments (including medications and physical therapy) and for whom surgery is not indicated. Properly selecting patients who meet specific criteria (based on historical results from randomized controlled trials), who diligently adhere to implant usage and precisely implement neuromuscular rehabilitation, improve success of significant functional recovery, as well as pain medication reductions. Patients with nociceptive mechanical CLBP who underwent implanted multifidus neurostimulation have been treated by physicians and rehabilitation specialists who have honed their experience working with multifidus neurostimulation. They have collaborated on consensus and evidence-driven guidelines to improve quality outcomes and to assist providers when encountering patients with this device. Physicians and physical therapists together provide precision patient-centric medical management with quality neuromuscular rehabilitation to encourage patients to be experts of both their implants and quality spine motion to help override long-standing multifidus dysfunction related to their CLBP.

Poor lumbar spine coordination in acute low back pain predicts persistent long-term pain and disability

PURPOSE

Sitting balance on an unstable surface requires coordinated out-of-phase lumbar spine and provides sufficient challenge to expose quality of spine control. We investigated whether the quality of spine coordination to maintain balance in acute low back pain (LBP) predicts recovery at 6 months.

METHODS

Participants in an acute LBP episode (n = 94) underwent assessment of sitting balance on an unstable surface. Seat, hip and spine (lower lumbar, lumbar, upper lumbar, thoracic) angular motion and force plate data were recorded. Coordination between the seat and hip/spine segments to maintain balance was quantified in the frequency domain to evaluate coordination (coherence) and relative timing (phase angle: in-phase [segments move together]; out-of-phase [segments move opposite]). Center of pressure (CoP) and upper thorax motion assessed overall balance performance. Hip and spine coordination with the seat were compared between those who did not recover (increased/unchanged pain/disability), partially recovered (reduced pain/disability) or recovered (no pain and disability) at 6 months.

RESULTS

In both planes, coherence between the seat and lower lumbar spine was lower (and in-phase-unhelpful for balance) at baseline in those who did not recover than those who recovered. Coherence between the seat and hip was higher in partially recovered in both planes, suggesting compensation by the hip. LBP groups had equal overall balance performance (CoP, upper thorax motion), but non-recovery groups used a less optimal strategy that might have consequences for long-term spine health.

CONCLUSION

These longitudinal data revealed that individuals with compromised contribution of the lumbar spine to the balance during unstable sitting during acute LBP are less likely to recover.

BACK-to-MOVE: Machine learning and computer vision model automating clinical classification of non-specific low back pain for personalised management

BACKGROUND

Low back pain (LBP) is a major global disability contributor with profound health and socio-economic implications. The predominant form is non-specific LBP (NSLBP), lacking treatable pathology. Active physical interventions tailored to individual needs and capabilities are crucial for its management. However, the intricate nature of NSLBP and complexity of clinical classification systems necessitating extensive clinical training, hinder customised treatment access. Recent advancements in machine learning and computer vision demonstrate promise in characterising NSLBP altered movement patters through wearable sensors and optical motion capture. This study aimed to develop and evaluate a machine learning model (i.e., 'BACK-to-MOVE') for NSLBP classification trained with expert clinical classification, spinal motion data from a standard video alongside patient-reported outcome measures (PROMs).

METHODS

Synchronised video and three-dimensional (3D) motion data was collected during forward spinal flexion from 83 NSLBP patients. Two physiotherapists independently classified them as motor control impairment (MCI) or movement impairment (MI), with conflicts resolved by a third expert. The Convolutional Neural Networks (CNNs) architecture, HigherHRNet, was chosen for effective pose estimation from video data. The model was validated against 3D motion data (subset of 62) and trained on the freely available MS-COCO dataset for feature extraction. The Back-to-Move classifier underwent fine-tuning through feed-forward neural networks using labelled examples from the training dataset. Evaluation utilised 5-fold cross-validation to assess accuracy, specificity, sensitivity, and F1 measure.

RESULTS

Pose estimation's Mean Square Error of 0.35 degrees against 3D motion data demonstrated strong criterion validity. Back-to-Move proficiently differentiated MI and MCI classes, yielding 93.98% accuracy, 96.49% sensitivity (MI detection), 88.46% specificity (MCI detection), and an F1 measure of .957. Incorporating PROMs curtailed classifier performance (accuracy: 68.67%, sensitivity: 91.23%, specificity: 18.52%, F1: .800).

CONCLUSION

This study is the first to demonstrate automated clinical classification of NSLBP using computer vision and machine learning with standard video data, achieving accuracy comparable to expert consensus. Automated classification of NSLBP based on altered movement patters video-recorded during routine clinical examination could expedite personalised NSLBP rehabilitation management, circumventing existing healthcare constraints. This advancement holds significant promise for patients and healthcare services alike.

Disability reduction following a lumbar stabilization exercise program for low back pain: large vs. small improvement subgroup analyses of physical and psychological variables

BACKGROUND

Little is known about why patients with low back pain (LBP) respond differently to treatment, and more specifically, to a lumbar stabilization exercise program. As a first step toward answering this question, the present study evaluates how subgroups of patients who demonstrate large and small clinical improvements differ in terms of physical and psychological changes during treatment.

METHODS

Participants (n = 110) performed the exercise program (clinical sessions and home exercises) over eight weeks, with 100 retained at six-month follow-up. Physical measures (lumbar segmental instability, motor control impairments, range of motion, trunk muscle endurance and physical performance tests) were collected twice (baseline, end of treatment), while psychological measures (fear-avoidance beliefs, pain catastrophizing, psychological distress, illness perceptions, outcome expectations) were collected at four time points (baseline, mid-treatment, end of treatment, follow-up). The participants were divided into three subgroups (large, moderate and small clinical improvements) based on the change of perceived disability scores. ANOVA for repeated measure compared well-contrasted subgroups (large vs. small improvement) at different times to test for SUBGROUP × TIME interactions.

RESULTS

Statistically significant interactions were observed for several physical and psychological measures. In all these interactions, the large- and small-improvement subgroups were equivalent at baseline, but the large-improvement subgroup showed more improvements over time compared to the small-improvement subgroup. For psychological measures only (fear-avoidance beliefs, pain catastrophizing, illness perceptions), between-group differences reached moderate to strong effect sizes, at the end of treatment and follow-up.

CONCLUSIONS

The large-improvement subgroup showed more improvement than the small-improvement subgroup with regard to physical factors typically targeted by this specific exercise program as well as for psychological factors that are known to influence clinical outcomes.

Gender Equality in Diastasis Rectus Abdominis in Chronic Back Pain: A Model of M. Transversus Abdominis Motor Control Impairment

Introduction: Diastasis rectus abdominis (DRA) is defined as an increased distance between the left and right muscle of the m. rectus abdominis. Pregnancy-related factors are assumed to be dominant factors in the occurrence of DRA. However DRA is not only found in peri-partum women but also in men and nulliparous women with back or pelvic pain. This study provides an inventory of the incidence of DRA in subjects with chronic back and pelvic pain. If DRA is common in both men and women then other factors besides pregnancy, like impaired motor control, should be explored as cause for DRA. Material and Methods: This study was conducted with data from 849 back pain patients. Results from ultrasound assessment of the abdominal wall were combined with anamnestic data on age, gender, medical history and pregnancies (in women). Results: There was no difference in Inter Rectus Distance cranial of the umbilicus (IRD above umbilicus) between men and women. Almost half of all women and men (45% and 43%, respectively) exhibit an increased IRD above umbilicus. The incidence of an increased IRD above umbilicus is twice as high in women below 30 years, compared to men below 30 years old. This difference is not observed for men and women above 30 years old. Discussion: DRA occurs in women during pregnancy and increases with an increasing number of pregnancies. However, this condition does not affect significantly more women than men. Increased IRD above umbilicus already occurs in young men (mean age 30). Over 30 years of age, cranial of the umbilicus there is no difference in IRD between women and men. An alternative etiological mechanism is suggested.

How do people with chronic low back pain pick a pencil off the floor?

BACKGROUND

Picking objects off the floor is provocative for people with chronic low back pain (CLBP). There are no clinically applicable methods evaluating movement strategies for this task. The relationship between strategy and multidimensional profiles is unknown.

OBJECTIVE

Develop a movement evaluation tool (MET) to examine movement strategies in people with CLBP (n = 289) picking a pencil off the floor. Describe those movement strategies, and determine reliability of the MET. Explore differences across multidimensional profiles and movement strategies.

METHODS

An MET was developed using literature and iterative processes, and its inter-rater agreement determined. Latent class analysis (LCA) derived classes demonstrating different strategies using six movement parameters as indicator variables. Differences between classes across multidimensional profiles were investigated using analysis of variance, Kruskal-Wallis, or chi-squared tests.

RESULTS

Six movement parameters were evaluated. There was substantial inter-rater agreement (Cohen's Kappa = 0.39-0.79) across parameters. LCA derived three classes with different strategies: Class 1 (71.8%) intermediate trunk inclination/knee flexion; Class 2 (24.5%) greater forward trunk inclination, lower knee flexion; Class 3 (3.7%) lower forward trunk inclination, greater knee flexion. Pain duration differed across all classes (p ≤ .001). Time taken to complete forward bends differed between Class 3 and other classes (p = .024).

CONCLUSIONS

Movement strategies can be reliably assessed using the MET. Three strategies for picking lightweight objects off the floor were derived, which differed across pain duration and speed of movement.

Don't Just Stand There. Rethinking the Ideal Body Posture for Otorhinolaryngologists

Surgeons have a high rate of work-related musculoskeletal injuries; an area that has received little attention. These injuries result in surgeons performing less efficiently, needing to take time off work, suffering higher rates of burnout, and may ultimately lead surgeons to retire earlier than planned. Otorhinolaryngologists are at particular risk for work-related musculoskeletal injuries. Beyond the clinician, sustaining such injuries can negatively impact patient safety. Ergonomic interventions have been used effectively to reduce work-related musculoskeletal injuries in other professions, yet not in surgery. With traditional teachings of ideal body postures to avoid injury and manual handling training being re-evaluated, it is important to explore evidence based interventions for reducing work-related musculoskeletal injuries in otorhinolaryngologists. New research encourages us to shift the focus away from the traditional one-size-fits-all approach to ergonomics and toward postural recommendations and education that promote a dynamic, individualized approach to avoiding sustained, static and awkward postures.

Direction-Specific Changes in Trunk Muscle Synergies in Individuals With Extension-Related Low Back Pain

Background Identifying altered trunk control is critical for treating extension-related low back pain (ERLBP), a common subgroup classified by clinical manifestations. The changed coordination of trunk muscles within this group during particular trunk tasks is still not clearly understood. Objectives The objective of this study is to investigate trunk muscle coordination during 11 trunk movement and stability tasks in individuals with ERLBP compared to non-low back pain (LBP) participants. Methods Thirteen individuals with ERLBP and non-LBP performed 11 trunk movement and stability tasks. We recorded the electromyographic activities of six back and abdominal muscles bilaterally. Trunk muscle coordination was assessed using the non-negative matrix factorization (NMF) method to identify trunk muscle synergies. Results The number of synergies in the ERLBP group during the cross-extension and backward bend tasks was significantly higher than in the non-LBP group (p<0.05). The cluster analysis identified the two trunk synergies for each task with strikingly similar muscle activation patterns between groups. In contrast, the ERLBP group exhibited additional trunk muscle synergies that were not identified in the non-LBP group. The number of synergies in the other tasks did not differ between groups (p>0.05). Conclusion Individuals with ERLBP presented directionally specific alterations in trunk muscle synergies that were considered as increased coactivations of multiple trunk muscles. These altered patterns may contribute to the excessive stabilization of and the high frequency of hyperextension in the spine associated with the development and persistence of ERLBP.

Effects of Movement Retraining and Lumbar Stabilization Exercises in Mechanical Low Back Pain: A Pilot Study

Objective To determine and compare the effects of movement retraining (MR), lumbar stabilization exercises (LSE), and a combination of both these exercises on pain, flexibility, strength, and functional disability in chronic mechanical low back pain (CMLBP) patients. Materials and methods Fifteen CMLBP participants, aged 20-40 years, were randomly allocated into three groups. Group A (n=5) received MR, group B (n=5), LSE, and group C (n=5), a combination of MR and CSE, along with hot packs for eight weeks, thrice a week on alternate days. Outcomes used were the Numerical Pain Rating Scale (NPRS), Modified Modified Schober's Test (MMST), Pressure Biofeedback (PBU), Roland Morris Disability Questionnaire (RMDQ), and Movement Control (MC) dissociation tests to identify MC impairments and were assessed at pre-intervention, post-four weeks, and post-eight weeks. The data were analyzed using repeated measures ANOVA. The level of significance was considered at p-value<0.05. Results Participants with CMLBP significantly improved in all variables in all three groups (p-value≤0.05). On inter-group comparison, group A showed better improvement in lumbar extension range of motion than the other two groups, with a mean difference of MMST in group A of 0.62±0.30, group B of 0.52±0.22, and group C of 0.36±0.02, with a p-value ≤0.002. Group C showed more improvement in core strength, with a mean difference of 5.0±0.25 in group A, 3.2±0.56 in group B, and 5.2±0.57 in group C, with a p-value ≤0.03. A significant improvement was observed in NPRS, MMST flexion, RMDQ, and uncontrolled movements (UCMs). Conclusion All three methods of treatment are effective in the management of CMLBP. Clinically, kinetic control showed better improvement in reducing pain and improving lumbar flexion and extension range of motion. Functional disability was better improved with lumbar stabilization exercises, and core strength was improved with a combination of KC and LSE. However, a combination of MR and LSE helps improve core strength, and movement retraining improves lumbar extension.

Biopsychosocial rehabilitation in the working population with chronic low back pain: a concept analysis

OBJECTIVE

To identify the essential attributes of biopsychosocial rehabilitation for chronic low back pain in the working population.

DESIGN

A concept analysis was conducted according to the 8-step method of Walker and Avant. This framework provides a clear concept and theoretical and operational definitions.

METHODS

Five databases were searched, followed by a systematic screening. Subsequently, attributes, illustrative cases, antecedents, consequences and empirical referents were formulated.

RESULTS

Of the 3793 studies identified, 42 unique references were included. Eleven attributes were identified: therapeutic exercise, psychological support, education, personalization, self-management, participation, follow-up, practice standard, goal-setting, social support, and dietary advice. Subsequently, illustrative cases were described. Antecedents, such as motivation, preparedness and a multidisciplinary team, were found, together with consequences such as decreased pain, less sick-leave and increased function and work status. Finally, examples of empirical referents were given.

CONCLUSION

This study identified the attributes that are necessary to develop biopsychosocial rehabilitation intervention programmes for chronic low back pain. The defined concept of biopsychosocial rehabilitation for chronic low back pain may serve as a solid base to further develop and apply interventions. Future research should focus on the objectification of biopsychosocial rehabilitation and conceptualization regarding how personalization is done.

How to tackle non-specific low back pain among adult patients? A systematic review with a meta-analysis to compare four interventions

OBJECTIVE

To tackle non-specific low back pain (NSLBP) among patients and find the most effective solution and to quantitatively synthesize the overall effect of motor control training (MCT) compared with Pilates, McKenzie method, and physical therapy (PT) in pain and physical function.

METHODS

Randomized controlled trials (RCTs) of four types of intervention (MCT, Pilates, McKenzie method, and PT) for LBP were collected by searching PubMed, Web of Science, EBSCOhost (Cochrane Central Register of Controlled Trials), and Scopus databases from the establishment of the database to September 30, 2023. The risk of bias was evaluated for included studies using the Revised Cochrane Risk of Bias tool for randomized trials (RoB 2.0). Taking pain and physical function in the experimental and control groups as outcome indicators, subgroup analysis was performed according to the intervention method to calculate the standardized mean difference (SMD) and 95% confidence interval (CI).

RESULTS

A total of 25 RCTs, including 1253 patients, were included. Meta-analysis showed that MCT effectively relieved pain [SMD = -0.65, 95% CI (- 1.00, - 0.29), p < 0.01] and improved physical function [SMD = -0.76, 95% CI (- 1.22, - 0.31), p < 0.01] comparing with other 3 types of intervention. Subgroup analysis suggested that MCT could alleviate pain [SMD = -0.92, 95% CI (- 1.34, - 0.50), p < 0.01] and improve physical function [SMD = -1.15, 95% CI (- 1.72, - 0.57), p < 0.01] compared with PT, but it had no statistical significance compared with Pilates [pain: SMD = 0.13, 95% CI (- 0.56, 0.83), p = 0.71; physical function: SMD = 0.10, 95% CI (- 0.72, 0.91), p = 0.81] and the McKenzie method [pain: SMD = -0.03, 95% CI (- 0.75, 0.68), p = 0.93; physical function: SMD = -0.03, 95% CI (- 1.00, 0.94), p = 0.95].

CONCLUSIONS

MCT can effectively relieve pain and improve physical function in patients with NSLBP. It is more effective compared with PT for LBP, while no differences were detected between MCT and Pilates, as well as McKenzie method. Therefore, MCT, Pilates, and the McKenzie method should be encouraged as exercise interventions for NSLBP rehabilitation.

Sexual Disability in Low Back Pain: Diagnostic and Therapeutic Framework for Physical Therapists

BACKGROUND

The literature shows a relationship between sexual activity and low back pain (LBP). The aim of this work is to provide a theoretical framework and practical proposal for the management of sexual disability in individuals with LBP.

METHODS

Based on a literature review, a team of specialized physical therapists developed a pattern for the management of LBP-related sexual disability.

RESULTS

A patient reporting LBP-related sexual disability may be included in one of four clinical decision-making pathways corresponding to one of the following: #1 standard physical therapy (PT); #2 psychologically informed physical therapy (PIPT); #3 PIPT with referral; or #4 immediate referral. Standard PT concerns the management of LBP-related sexual disability in the absence of psychosocial or pathological issues. It includes strategies for pain modulation, stiffness management, motor control, stabilization, functional training, pacing activities comprising education, and stay-active advice. PIPT refers to patients with yellow flags or concerns about their relationship with partners; this treatment is oriented towards a specific psychological approach. "PIPT with referral" and "Immediate referral" pathways concern patients needing to be referred to specialists in other fields due to relationship problems or conditions requiring medical management or pelvic floor or sexual rehabilitation.

CONCLUSIONS

The proposed framework can help clinicians properly manage patients with LBP-related sexual disability.

Impaired Lumbar Extensor Force Control Is Associated with Increased Lifting Knee Velocity in People with Chronic Low-Back Pain

The ability of the lumbar extensor muscles to accurately control static and dynamic forces is important during daily activities such as lifting. Lumbar extensor force control is impaired in low-back pain patients and may therefore explain the variances in lifting kinematics. Thirty-three chronic low-back pain participants were instructed to lift weight using a self-selected technique. Participants also performed an isometric lumbar extension task where they increased and decreased their lumbar extensor force output to match a variable target force within 20-50% lumbar extensor maximal voluntary contraction. Lifting trunk and lower limb range of motion and angular velocity variables derived from phase plane analysis in all planes were calculated. Lumbar extensor force control was analyzed by calculating the Root-Mean-Square Error (RMSE) between the participants' force and the target force during the increasing (RMSEA), decreasing (RMSED) force portions and for the overall force error (RMSET) of the test. The relationship between lifting kinematics and RMSE variables was analyzed using multiple linear regression. Knee angular velocity in the sagittal and coronal planes were positively associated with RMSEA (R2 = 0.10, β = 0.35, p = 0.046 and R2 = 0.21, β = 0.48, p = 0.004, respectively). Impaired lumbar extensor force control is associated with increased multiplanar knee movement velocity during lifting. The study findings suggest a potential relationship between lumbar and lower limb neuromuscular function in people with chronic low-back pain.

A model for personalized diagnostics for non-specific low back pain: the role of the myofascial unit

Low back pain (LBP) is the leading cause of disability worldwide. Most LBP is non-specific or idiopathic, which is defined as symptoms of unknown origin without a clear specific cause or pathology. Current guidelines for clinical evaluation are based on ruling out underlying serious medical conditions, but not on addressing underlying potential contributors to pain. Although efforts have been made to identify subgroups within this population based on response to treatment, a comprehensive framework to guide assessment is still lacking. In this paper, we propose a model for a personalized mechanism-based assessment based on the available evidence that seeks to identify the underlying pathologies that may initiate and perpetuate central sensitization associated with chronic non-specific low back pain (nsLBP). We propose that central sensitization can have downstream effects on the "myofascial unit", defined as an integrated anatomical and functional structure that includes muscle fibers, fascia (including endomysium, perimysium and epimysium) and its associated innervations (free nerve endings, muscle spindles), lymphatics, and blood vessels. The tissue-level abnormalities can be perpetuated through a vicious cycle of neurogenic inflammation, impaired fascial gliding, and interstitial inflammatory stasis that manifest as the clinical findings for nsLBP. We postulate that our proposed model offers biological plausibility for the complex spectrum of clinical findings, including tissue-level abnormalities, biomechanical dysfunction and postural asymmetry, ecological and psychosocial factors, associated with nsLBP. The model suggests a multi-domain evaluation that is personalized, feasible and helps rule out specific causes for back pain guiding clinically relevant management. It may also provide a roadmap for future research to elucidate mechanisms underlying this ubiquitous and complex problem.

Individual endogenous pain modulation profiles within a multidimensional context of people with cervicogenic headache - A retrospective exploratory study

BACKGROUND

One in four individuals with cervicogenic headache (CeH) are unresponsive to therapy. Such therapy involves predominantly biomedical interventions targeting the upper-cervical spine. A recurring theme within musculoskeletal practice is the multidimensional nature and substantial heterogeneity of the condition. Such heterogeneity might be a reason for failure of a biomedical approach. Therefore, future studies investigating efficacy of managing CeH should ideally be based on identification, and better understanding of the heterogeneity of this population based on a comprehensive evaluation of clinically relevant contributing factors.

OBJECTIVES

The objective was to map profiles of individuals with CeH based on pain modulation within a multidimensional context.

DESIGN

Pain Modulation Profiles (PMPs) of 18 adults (29-51 years) with CeH were mapped retrospectively.

METHOD

The PMPs consisted of a Pain-Profile (bilateral suboccipital, erector spinae, anterior tibialis pressure pain thresholds), a Psycho-Social-Lifestyle-Profile (Depression, Anxiety, Stress Scale, Headache Impact test, Pittsburgh Sleep Quality Index), or a combination of both. Individual results were compared to normative data. Two Pain-Profiles were defined: normal or altered. Psycho-Social-Lifestyle-Profiles were categorized based on the number of altered psycho-social-lifestyle factors (range 0-5).

RESULTS

Mapping PMPs in individuals with CeH resulted in 50% presenting with a dominant altered Pain-Profile, 16.7% with a dominant altered Psycho-Social-Lifestyle-Profile, and 5.6% with dominant alterations in both Pain-Profile and Psycho-Social-Lifestyle-Profile.

CONCLUSION

Our results indicate heterogeneity of PMPs within the CeH population. Replication of these results is needed through dynamic assessment of the Pain-Profile before evaluating if these profiles can help patient-stratification.

Not all movements are equal: Differences in the variability of trunk motor behavior between people with and without low back pain-A systematic review with descriptive synthesis

BACKGROUND

Differences in variability of trunk motor behavior between people with and without low back pain (LBP) have been reported in the literature. However, the direction and consistency of these differences remain unclear. Understanding variability of trunk motor behavior between individuals with LBP and those without is crucial to better understand the impact of LBP and potentially optimize treatment outcomes. Identifying such differences may help tailor therapeutic interventions.

OBJECTIVE

This systematic review aims to answer the question: Is variability of trunk motor behavior different between people with and without LBP and if so, do people with LBP show more or less variability? Furthermore, we addressed the question whether the results are dependent on characteristics of the patient group, the task performed and the type of variability measure.

METHODS

This study was registered in PROSPERO (CRD42020180003). A comprehensive systematic literature search was performed by searching PubMed, Embase, Cinahl, Cochrane Central Register of Controlled Trials, Web of Science and Sport Discus. Studies were eligible if they (1) included a LBP group and a control group, (2) included adults with non-specific low back pain of any duration and (3) measured kinematic variability, EMG variability and/or kinetic variability. Risk of Bias was evaluated and a descriptive synthesis was performed.

RESULTS

Thirty-nine studies were included, thirty-one of which were included in the descriptive synthesis. In most studies and experimental conditions, variability did not significantly differ between groups. When significant differences were found, less variability in patients with LBP was more frequently reported than more variability, especially in gait-related tasks.

CONCLUSIONS

Given the considerable risk of bias of the included studies and the clinical characteristics of the participants with low severity scores for pain, disability and psychological measures, there is insufficient evidence to draw firm conclusions.

The Observable Movement Quality scale for patients with low back pain (OMQ-LBP): validity and reliability in a primary care setting of physical therapy

BACKGROUND

The Observable Movement Quality scale for patients with low back pain (OMQ-LBP) is a newly developed measurement instrument for use in primary care settings of physical and exercise therapists to assess movement quality (MQ) of patients with low back pain (LBP).

OBJECTIVE

This study aims to determine validity, reliability and feasibility of the OMQ-LBP. The OMQ-LBP consists of a standardized movement circuit (performed twice) consisting of five daily activities problematic for LBP patients, which are scored with an 11-item observation list.

METHODS

Construct validity was determined by testing seven hypotheses on associations between constructs (n = 85 patients with LBP) and four hypotheses on known group differences (n = 85 patients with LBP and n = 63 healthy controls; n = 35 matched participant-patients having VAS-pain ≥ 20 mm during and/or after both circuits and healthy controls). Internal consistency was analyzed with Cronbach's alpha (n = 85 patients with LBP). For inter- and intra-rater reliability Intraclass Correlation Coefficient (ICC) values were examined (n = 14 therapists: seven primary care physical therapists and seven exercise therapists). Additionally, content validity and feasibility were determined using thematic analysis of a brief interview with participants, patients (n = 38) and therapists (n = 14).

RESULTS

After Bonferroni correction 2/7 associations between constructs and 2/4 significant group differences were confirmed. Cronbach's alpha was 0,79. The ICC-values of interrater reliability of the OMQ-LBP total score and the duration score were 0.56 and 0.99 and intra-rater reliability 0.82 and 0,93, respectively. Thematic analysis revealed five themes. Three themes elucidate that both patients and therapists perceived the content of the OMQ-LBP as valid. The fourth theme exhibits that OMQ-LBP provides a clear and unambiguous language for MQ in patients with LBP. Theme 5 depicts that the OMQ-LBP seems feasible, but video recording is time-consuming.

CONCLUSIONS

The OMQ-LBP is a promising standardized observational assessment of MQ during the five most problematic daily activities in patients with LBP. It is expected that uniform and objective description and evaluation of MQ add value to clinical reasoning and facilitate uniform communication with patients and colleagues.

Test-retest reliability and construct validity of trunk extensor muscle force modulation accuracy

Low back pain is associated with changes in trunk muscle structure and function and motor control impairments. Voluntary force modulation (FM) of trunk muscles is a unique and under-investigated motor control characteristic. One of the reasons for this paucity of evidence is the lack of exploration and publication on the reliability and validity of trunk FM protocols. The purpose of this study was to determine the within- and between-day test-retest reliability and construct validity for trunk extensor muscle FM. Twenty-nine healthy participants were tested under three FM conditions with different modulation rates. Testing was performed on a custom-built apparatus designed for trunk isometric force testing. FM accuracy relative to a fluctuating target force (20-50%MVF) was quantified using the root mean square error of the participant's generated force relative to the target force. Reliability and precision of measurement were assessed using the Intraclass Correlation Coefficient (ICC), standard error of measurement (SEM), minimal detectable difference (MDD95), and Bland-Altman plots. In a subset of participants, we collected surface electromyography of trunk and hip muscles. We used non-negative matrix factorization (NNMF) to identify the underlying motor control strategies. Within- and between-day test-retest reliability was excellent for FM accuracy across the three conditions (ICC range: 0.865 to 0.979). SEM values ranged 0.9-1.8 Newtons(N) and MDD95 ranged from 2.4-4.9N. Conditions with faster rates of FM had higher ICCs. NNMF analysis revealed two muscle synergies that were consistent across participants and conditions. These synergies demonstrate that the muscles primarily involved in this FM task were indeed the trunk extensor muscles. This protocol can consistently measure FM accuracy within and between testing sessions. Trunk extensor FM, as measured by this protocol, is not specific to any trunk muscle group but is the result of modulation by all the trunk extensor muscles.

Reliability of two lumbar motor control tests for people with low back pain that are feasible in clinical practice

BACKGROUND

Clinically feasible and reliable methods to measure motor control in people with low back pain (LBP) are lacking. This reliability and measurement error study design (i.e. repeated measurements in stable patients) aimed to determine the intra- and interrater reliability, and measurement errors of several parameters for two clinical lumbar motor control tests.

METHOD

Participants 18-65 years of age, with current or a history of LBP performed a spiral tracking task (n = 33; i.e., tracing a spiral on a computer monitor by making spinal movements) or a repositioning task (n = 34; i.e., returning the trunk to a predefined position). Accelerometers were used to measure trunk positions. To explore the potential of these tests, we evaluated a broad range of parameters. To assess intra- and interrater reliability, we calculated the intraclass correlation coefficient (ICC(2,1) for absolute agreement), standard error of measurement and smallest detectable change for each parameter.

FINDINGS

Overall, the interrater reliability of the spiral tracking test was good (ICC>0.75). The reliability of the second and third trial revealed higher ICC values compared to the reliability of the first two trials. The intra- and interrater reliability of the repositioning test was overall poor (ICC <0.5, with the exception of trunk inclination: ICC: 0.5 to 0.75).

CONCLUSION

The reliability and set-up of the spiral tracking test supports its feasibility for clinical use. Considering the poor reliability of the repositioning test, it is doubtful whether further development of this measurement protocol is indicated. Only for the direction trunk inclination further standardisation might be warranted.

Respiratory Function Analysis in Patients with Chronic Pain: An Umbrella Review and Meta-Analysis of Pooled Findings

BACKGROUND

The main aim of this umbrella review was to assess the respiratory function in patients with chronic pain (CP), including patients with chronic neck pain (CNP), chronic low back pain (CLBP), and fibromyalgia syndrome (FMS).

METHODS

We searched in PubMed, PEDro, EMBASE, CINAHL, and Google Scholar (4 February 2023). The outcome measures were respiratory muscle strength (MIP/MEP) and pulmonary function (VC, MVV, FVC, FEV₁, FEV₁/FVC ratio, FEV_25-75, and PEF). This review was previously registered in the international prospective register of systematic reviews, PROSPERO (CRD42023396722). The methodological quality was analyzed using AMSTAR and ROBIS scales, and the strength of the evidence was established according to the guidelines advisory committee grading criteria. To compare the outcomes reported by the studies, we calculated the standardized mean differences and the corresponding 95% confidence interval for the continuous variables.

RESULTS

Four systematic reviews with and without meta-analysis were included, from which a total of 15 primary studies were extracted. Five meta-analyses were carried out, using analyses by subgroup according to the type of CP. The meta-analyzing variables were MIP, MEP, MVV, FEV₁, and FVC.

CONCLUSIONS

Overall, patients with CP have decreased respiratory muscle strength with a moderate quality of evidence. Regarding the pulmonary function, patients with CNP showed a diminished VC, PEF, MVV, FEV₁, and FVC, while FEV_25-75 and the FEV₁/FVC ratio were conserved with a limited to moderate quality of evidence. Finally, patients with FMS and CLBP only showed a decrease in MVV with a limited quality of evidence.

Delayed response in rectus abdominis muscle following a step perturbation in subjects with and without recurrent low back pain

BACKGROUND

Delayed trunk and lower limb muscle activation is associated with balance loss and fall injuries in subjects with recurrent low back pain (LBP).

PURPOSE

This study was conducted to compare differences in the onset of muscle contractions of the trunk and lower limb muscles following a treadmill-induced step perturbation between subjects with and without LBP.

METHODS

Eighty-three right limb dominant individuals (43 subjects with LBP and 40 control subjects) were exposed to the perturbation (0.31 m/s velocity for 0.2 m). The electromyography (EMG) reaction times were analyzed during the first step following the perturbation. The EMG electrodes were placed on both sides of the trunk and lower limbs, including the rectus abdominis (RA), erector spinae (ES), tibialis anterior (TA), and gastrocnemius (GA) muscles.

RESULTS

The group x muscle interaction was statistically significant (F = 9.44, p = 0.003). The TA muscle activation was significantly delayed compared to the RA, ES, and GA. There was a significant interaction on side x muscle (F = 4.14, p = 0.04). The RA muscles were significantly delayed on the non-dominant (t = - 3.35, p = 0.001) and dominant (t = - 2.53, p = 0.01) sides in the LBP group.

CONCLUSION

The LBP group demonstrated a delayed reaction time on the RA muscles, which indicated poor trunk control relative to the lower limbs. The delayed bilateral RA muscle might indicate possible coordination problems relative to the ES and lower limb muscles, which may lead to potential fall hazards.

Mind-Body Exercise Performed by Physical Therapists for Reducing Pain and Disability in Low Back Pain: A Systematic Review With Meta-analysis

OBJECTIVE

To assess the effectiveness of mind-body (MB) exercise interventions provided by physical therapists for reducing pain and disability in people with low back pain (LBP).

DATA SOURCES

MEDLINE, Embase, CINAHL, and the Cochrane Library were searched for articles published in English between December 2010 and June 2020.

STUDY SELECTION

Randomized controlled trials evaluating the effects of Pilates, yoga, and tai chi interventions performed by physical therapists on pain or disability outcomes in adults with musculoskeletal LBP were included.

DATA EXTRACTION

Data were extracted by 2 independent reviewers. Quality of evidence and risk of bias were assessed using the Grading of Recommendations Assessment, Development, and Evaluation framework and Cochrane risk of bias tools, respectively.

DATA SYNTHESIS

21,230 exercise trials were identified; 161 progressed to full-text review. Eight trials, 7 reporting on Pilates and 1 reporting on yoga, were included. Short-term outcomes for pain (SMD: -0.93; 95% confidence interval [CI]: -1.65 to -0.021) and disability (SMD: -0.74 95% CI: -1.36 to -0.012) indicated MB exercise was more effective than control intervention. Tests for subgroup differences between studies with exercise vs non-exercise control groups revealed a moderating effect on short-term outcomes where larger effects were observed in studies with non-exercise comparators. Long-term outcomes for pain (SMD: -0.60; 95% CI:-1.43 to 0.23) and disability (SMD: -1.05; 95% CI:-3.51 to 1.41) suggested that MB exercise is not more effective than control interventions for pain or disability. Quality of the evidence ranged from very low to low.

CONCLUSIONS

Physical therapist-delivered MB exercise interventions, which overwhelmingly consisted of Pilates, were more effective than control in the short and long-term for pain and in the short-term for disability, with differences in the short-term effects lessened when compared with an active intervention. Pilates interventions delivered by physical therapists represent a viable tool for the clinical management of chronic LBP.

Education of physiotherapists improves inter-rater reliability in lumbar spine motor control tests: A randomized controlled trial

OBJECTIVES

To determine the effect of 1-h education session, compared with no education, on physiotherapists' (PTs) inter-rater reliability in two lumbar spine motor control tests (MCTs): waiter's bow (WB) and sitting knee extension (SKE). To determine whether reliability at baseline and the effect of education are affected by PT's clinical experience, knowledge and experience of MCTs, and post-graduate education in manual therapy.

DESIGN

Randomized controlled trial.

PARTICIPANTS

54 PTs.

INTERVENTION

The experimental group (EG) took part in a 1-h group education session. Control group (CG) had no intervention.

MEASUREMENTS

At baseline and after EG had completed the education session, therapists rated 40 SKE and 40 WB video recordings.

ANALYSIS

Changes in Fleiss' kappa were compared between groups. Differences >0.1 in kappa values were considered meaningful. Regression analysis was used to evaluate the effect of therapist's characteristics on inter-rater reliability at baseline and changes in inter-rater reliability.

RESULTS

Education had significant and meaningful effect on reliability compared with no education. WB kappa values improved from 0.36 to 0.63 in the experimental group and from .39 to .46 in the control group. SKE kappa values improved from .50 to .71 in the EG and from 0.49 to 0.57 in the CG. None of PTs' characteristics affected reliability at baseline or education effects.

CONCLUSION

The effect of 1-h group education session for physiotherapists on inter-rater reliability in MCTs is significant and meaningful. Provision of education for PTs in performing observational tests would improve inter-rater reliability, resulting in improved treatment planning and outcome evaluation.

Presentation, Diagnosis, and Management of Lower Back Pain Associated with Spinal Stenosis: A Narrative Review

Lower back pain (LBP) is an extremely common symptom experienced by people of all ages and is also one of the most frequent causes of disability worldwide. This article aims to review the presentation, diagnosis, and management of lower back pain associated with spinal stenosis. The paper we prepared was classified as a "literature narrative review." Nonetheless, when searching for manuscripts included in our work and reviewing them critically, we concentrated on the keywords: "lower back pain", "lumbar spine stenosis", "diagnostic", "rehabilitation", "neurosurgery", "spine", and "elderly". The incidence of chronic lower back pain (CLBP) increases linearly starting with the third decade of life until 60 years old, and it more often affects women. The course of non-specific LBP above all depends on factors not connected with the spine, which include psychological, behavioral, and social factors, determined by the way the condition is perceived by the patient the environment. Lumbar spine stenosis (LSS) is an age-related process of degeneration of the intervertebral discs, ligamentum flavum, and facet joints, which results in narrowing of the space around the neurovascular structures of the spine. Diagnosis of spinal pain syndromes includes radiography (RTG), computed tomography (CT), and magnetic resonance imaging (MRI). Based on the results of imaging studies, neurological examination, and the severity of the disease, treatment can consist of analgesics and rehabilitation, or, when conservative methods are insufficient, surgical treatment is indicated.

Variability of trunk muscle synergies underlying the multidirectional movements and stability trunk motor tasks in healthy individuals

Muscle synergy analysis is useful for investigating trunk coordination patterns based on the assumption that the central nervous system reduces the dimensionality of muscle activation to simplify movement. This study aimed to quantify the variability in trunk muscle synergy during various trunk motor tasks in healthy participants to provide reference data for evaluating trunk control strategies in patients and athletes. Sixteen healthy individuals performed 11 trunk movement and stability tasks with electromyography (EMG) recording of their spinal and abdominal muscles (6 bilaterally). Non-negative matrix factorization applied to the concatenated EMG of all tasks identified the five trunk muscle synergies (W) with their corresponding temporal patterns (C). The medians of within-cluster similarity defined by scalar products in W and rmax coefficient using the cross-correlation function in C were 0.73-0.86 and 0.64-0.75, respectively, while the inter-session similarities were 0.81-0.96 and 0.74-0.84, respectively. However, the lowest and highest values of both similarity indices were broad, reflecting the musculoskeletal system's redundancy within and between participants. Furthermore, the significant differences in the degree of variability between the trunk synergies may represent the different neural features of synergy organization and strategies to overcome the various mechanical demands of a motor task.

Associations between primary motor cortex organization, motor control and sensory tests during the clinical course of low back pain. A protocol for a cross-sectional and longitudinal case-control study

Background

In people with low back pain (LBP), altered motor control has been related to reorganization of the primary motor cortex (M1). Sensory impairments in LBP have also been suggested to be associated with reorganization of M1. Little is known about reorganization of M1 over time in people with LBP, and whether it relates to changes in motor control and sensory impairments and recovery. This study aims to investigate 1) differences in organization of M1 of trunk muscles between people with and without LBP, and whether the organization of M1 relates to motor control and sensory impairments (cross-sectional component) and 2) reorganization of M1 over time and its relation with changes in motor control and sensory impairments and experienced recovery (longitudinal component).

Methods

A case-control study with a cross-sectional and five-week longitudinal component is conducted in participants with LBP (N = 25) and participants without LBP (N = 25). Participants with LBP received usual care physiotherapy. Various tests were administered at baseline and follow-up. Following an anatomical MRI, organization of M1 (Center of Gravity and Area of the cortical representation of trunk muscles) was determined using transcranial magnetic stimulation. Quantitative sensory testing, a spiral-tracking motor control test, graphesthesia, two-point discrimination threshold and various self-reported questionnaires were also assessed. Multivariate multilevel analysis will be used for statistical analysis.

Conclusion

We will address the gaps in knowledge about the association between reorganization of M1 and motor control and sensory tests during the clinical course of LBP. This study is registered at DOI 10.17605/OSF.IO/5C8ZG.

•

We assess relations between the organization of M1 and motor and sensory tests.

•

This study provides insight in the organization of M1 in LBP in relation to recovery.

•

The organization of M1 is assessed via TMS.

•

We used whole-brain MRI's for high accuracy of representation of muscles on M1.

•

We will use multivariate mixed model analysis to relate M1, motor and sensory tests.

Investigation of the relationship between the clinical evaluation results of lumbar region muscles with cross-sectional area and fat infiltration

BACKGROUND

The relationship between the endurance of the lumbar paraspinal muscles and morphological changes needs to be clarified. In this context, the importance can be revealed of increasing the endurance level of the paraspinal muscles in the prevention and treatment of low back diseases.

OBJECTIVE

The aim of this study was to examine the relationship between the clinical evaluation results of the cross-sectional area (CSA) and fat infiltration of the lumbar deep paraspinal muscles.

METHODS

The study included 37 patients with mechanical low back pain (mechanical), 41 patients with lumbar hernia without root compression (discopathy) and 36 healthy individuals as a control group. The functional status of the lumbar deep paraspinal muscles was evaluated clinically with muscle endurance tests. The fat infiltration and CSA of the muscles were evaluated on axial MRI sections at the L3-S1 level.

RESULTS

The mean values of the prone bridge, Biering-Sorenson, and trunk flexion tests were seen to be highest in the control group and lowest in the discopathy group (p< 0.001). In all tests, the longest test period was obtained at < 10% fat infiltration and the shortest at > 50% fat infiltration. It was observed that as the amount of fat infiltration of the muscles increased, the test times were shortened. There was no significant relationship between the endurance level and the CSA of the groups.

CONCLUSION

The study results demonstrated that the endurance of the paraspinal muscles is associated with the fat infiltration of the muscles. In patients with chronic low back pain, information about muscle morphology and degeneration can be obtained with simple endurance tests without the need for further measurements. On clinical examination, a weak endurance level of the paraspinal muscles indicates the presence of a low back problem and an increase in the amount of fat infiltration.

S, Neelam S. Nonspecific low back pain in sedentary workers: A narrative review

A sedentary lifestyle is a risk factor, significantly increasing the incidence of low back pain (LBP). Higher levels of sedentary lifestyle were witnessed in the workers who spent the greatest amount of their time in sitting positions in the workplace and during free time. The incidence and prevalence of low back pain in sedentary workers were 14-37% and 34-62%. Noticeably, the people with low back pain had higher productivity loss. It specifies more research is required to help individuals with back pain to stay in their work. The main intention of this study briefly reviews the risk factors, associated adaptations, and Interventions in physical therapy for preventing and managing nonspecific low back pain in sedentary workers. To do this review, Information was gathered from the offline library resources and online electronic search databases (Scopus, COCHRANE, PUBMED). The keywords used were low back pain, sedentary workers, risk factors, adaptations, exercise therapy, and sedentary lifestyle. The prognosis and management of low back pain were greatly influenced by several risk factors related to physical, psychological, and occupational factors. During the transition of low back pain from acute to chronic stages, adaptations in various domains like psychological, behavioral, and neuromuscular changes are seen. Exercise therapy itself or in addition to other therapeutic approaches is successful in preventing and treatment of nonspecific low back pain in sedentary workforces. By identifying associated risk factors, and changes adapted by individual patients, Therapists can design proper exercise therapeutic approaches that will provide more effective interventions.

Individualized Exercise in Chronic Non-Specific Low Back Pain: A Systematic Review with Meta-Analysis on the Effects of Exercise Alone or in Combination with Psychological Interventions on Pain and Disability

This systematic review, meta-analysis and meta-regression investigated the effects of individualized interventions, based on exercise alone or combined with psychological treatment, on pain intensity and disability in patients with chronic non-specific low-back-pain. Databases were searched up to January 31, 2022 to retrieve respective randomized controlled trials of individualized and/or personalized and/or stratified exercise interventions with or without psychological treatment compared to any control. Fifty-eight studies (n = 10084) were included. At short-term follow-up (12 weeks), low-certainty evidence for pain intensity (SMD -0.28 [95%CI -0.42 to -0.14]) and very low-certainty evidence for disability (-0.17 [-0.31 to -0.02]) indicates effects of individualized versus active exercises, and very low-certainty evidence for pain intensity (-0.40; [-0.58 to -0.22])), but not (low-certainty evidence) for disability (-0.18; [-0.22 to 0.01]) compared to passive controls. At long-term follow-up (1 year), moderate-certainty evidence for pain intensity (-0.14 [-0.22 to -0.07]) and disability (-0.20 [-0.30 to -0.10]) indicates effects versus passive controls. Sensitivity analyses indicates that the effects on pain, but not on disability (always short-term and versus active treatments) were robust. Pain reduction caused by individualized exercise treatments in combination with psychological interventions (in particular behavioral-cognitive therapies) (-0.28 [-0.42 to -0.14], low certainty) is of clinical importance. Certainty of evidence was downgraded mainly due to evidence of risk of bias, publication bias and inconsistency that could not be explained. Individualized exercise can treat pain and disability in chronic non-specific low-back-pain. The effects at short term are of clinical importance (relative differences versus active 38% and versus passive interventions 77%), especially in regard to the little extra effort to individualize exercise. Sub-group analysis suggests a combination of individualized exercise (especially motor-control based treatments) with behavioral therapy interventions to booster effects. PERSPECTIVE: The relative benefit of individualized exercise therapy on chronic low back pain compared to other active treatments is approximately 38% which is of clinical importance. Still, sustainability of effects (> 12 months) is doubtable. As individualization in exercise therapies is easy to implement, its use should be considered. PROSPERO REGISTRATION: CRD42021247331.

Do people with low back pain walk differently? A systematic review and meta-analysis

BACKGROUND

The biomechanics of the trunk and lower limbs during walking and running gait are frequently assessed in individuals with low back pain (LBP). Despite substantial research, it is still unclear whether consistent and generalizable changes in walking or running gait occur in association with LBP. The purpose of this systematic review was to identify whether there are differences in biomechanics during walking and running gait in individuals with acute and persistent LBP compared with back-healthy controls.

METHODS

A search was conducted in PubMed, CINAHL, SPORTDiscus, and PsycINFO in June 2019 and was repeated in December 2020. Studies were included if they reported biomechanical characteristics of individuals with and without LBP during steady-state or perturbed walking and running. Biomechanical data included spatiotemporal, kinematic, kinetic, and electromyography variables. The reporting quality and potential for bias of each study was assessed. Data were pooled where possible to compare the standardized mean differences (SMD) between back pain and back-healthy control groups.

RESULTS

Ninety-seven studies were included and reviewed. Two studies investigated acute pain and the rest investigated persistent pain. Nine studies investigated running gait. Of the studies, 20% had high reporting quality/low risk of bias. In comparison with back-healthy controls, individuals with persistent LBP walked slower (SMD = -0.59, 95% confidence interval (95%CI): -0.77 to -0.42)) and with shorter stride length (SMD = -0.38, 95%CI: -0.60 to -0.16). There were no differences in the amplitude of motion in the thoracic or lumbar spine, pelvis, or hips in individuals with LBP. During walking, coordination of motion between the thorax and the lumbar spine/pelvis was significantly more in-phase in the persistent LBP groups (SMD = -0.60, 95%CI: -0.90 to -0.30), and individuals with persistent LBP exhibited greater amplitude of activation in the paraspinal muscles (SMD = 0.52, 95%CI: 0.23-0.80). There were no consistent differences in running biomechanics between groups.

CONCLUSION

There is moderate-to-strong evidence that individuals with persistent LBP demonstrate differences in walking gait compared to back-healthy controls.

A randomized controlled trial concerning the implementation of the postural Mézières treatment in elite athletes with low back pain

OBJECTIVE

This study aimed to evaluate the impact of adding the Mézières Method (MM) to the standard rehabilitation protocol for the elite athletes with low back pain (LBP) in reducing lumbar pain than only using the traditional rehabilitation protocol treatment. The disciplines considered in this study were soccer, rhythmic gymnastics, and basketball.

DESIGN

Randomized controlled trial.

SETTING

Training Camp.

PARTICIPANTS

One hundred thirty-nine elite athletes with low back pain of whom 69 were assigned to the experimental group.

INTERVENTION

The intervention consists of treatment with three lying postures in a 40-minutes long session twice a week. The session goal was to focus on breathing exercises, spine mobility, and stretching of the back muscles, with particular attention to the diaphragmatic, paravertebral, and latissimus dorsi muscles.

OUTCOME MEASURES

Assessments as Visual Analogue Scale (VAS), Sit and Reach flexibility test, Roland-Morris Questionnaire, and health status questionnaire (SF12) were used.

RESULTS

The evaluation of all outcomes in 4 measurement periods of the study (baseline, 4, 12, and 24 weeks) showed a significant difference between groups. Also, at the 6-month of the intervention, a significant difference in the means (SD) was observed in pain (VAS), back flexibility (Sit & Reach) and back disability (QRM) outcomes in favor of the experimental group with a medium-large effect size comparing with the control group.

CONCLUSION

The MM approach can also be applied in established conventional protocols to alleviate pain and functionality. The obtained results include improving the quality of life of the athletes and their physical and emotional states.

Clinical trial registration number ID: NCT03849053.

Does motor control training improve pain and function in adults with symptomatic lumbar disc herniation? A systematic review and meta-analysis of 861 subjects in 16 trials

OBJECTIVE

To evaluate the effectiveness of motor control training (MCT) compared with other physical therapist-led interventions, minimal/no intervention or surgery in patients with symptomatic lumbar disc herniation (LDH).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Eight databases and the ClinicalTrials.gov were searched from inception to April 2021.

ELIGIBILITY CRITERIA

We included clinical trial studies with concurrent comparison groups which examined the effectiveness of MCT in patients with symptomatic LDH. Primary outcomes were pain intensity and functional status which were expressed as mean difference (MD) and standardised mean difference (SMD), respectively.

RESULTS

We screened 6695 articles, of which 16 clinical trials (861 participants) were eligible. Fourteen studies were judged to have high risk of bias and two studies had some risk of bias. In patients who did not undergo surgery, MCT resulted in clinically meaningful pain reduction compared with other physical therapist-led interventions (ie, transcutaneous electrical nerve stimulation (TENS)) at short-term (MD -28.85, -40.04 to -17.66, n=69, studies=2). However, the robustness of the finding was poor. For functional status, a large and statistically significant treatment effect was found in favour of MCT compared with traditional/classic general exercises at long-term (SMD -0.83 to -1.35 to -0.31, n=63, studies=1) and other physical therapist-led interventions (ie, TENS) at short-term (SMD -1.43 to -2.41 to -0.46, n=69, studies=2). No studies compared MCT with surgery. In patients who had undergone surgery, large SMDs were seen. In favour of MCT compared with traditional/classic general exercises (SMD -0.95 to -1.32 to -0.58, n=124, studies=3), other physical therapist-led interventions (ie, conventional treatments; SMD -2.30 to -2.96 to -1.64, n=60, studies=1), and minimal intervention (SMD -1.34 to -1.87 to -0.81, n=68, studies=2) for functional improvement at short-term. The overall certainty of evidence was very low to low.

CONCLUSION

At short-term, MCT improved pain and function compared with TENS in patients with symptomatic LDH who did not have surgery. MCT improved function compared with traditional/classic general exercises at long-term in patients who had undergone surgery. However, the results should be interpreted with caution because of the high risk of bias in the majority of studies.

PROSPERO REGISTRATION NUMBER

CRD42016038166.

Unsupervised Machine Learning on Motion Capture Data Uncovers Movement Strategies in Low Back Pain

Chronic low back pain (LBP) is a leading cause of disability and opioid prescriptions worldwide, representing a significant medical and socioeconomic problem. Clinical heterogeneity of LBP limits accurate diagnosis and precise treatment planning, culminating in poor patient outcomes. A current priority of LBP research is the development of objective, multidimensional assessment tools that subgroup LBP patients based on neurobiological pain mechanisms, to facilitate matching patients with the optimal therapies. Using unsupervised machine learning on full body biomechanics, including kinematics, dynamics, and muscle forces, captured with a marker-less depth camera, this study identified a forward-leaning sit-to-stand strategy (STS) as a discriminating movement biomarker for LBP subjects. A forward-leaning STS strategy, as opposed to a vertical rise strategy seen in the control participants, is less efficient and results in increased spinal loads. Inefficient STS with the subsequent higher spinal loading may be a biomarker of poor motor control in LBP patients as well as a potential source of the ongoing symptomology.

Performance on a Motor Control Test in an Asymptomatic Adolescent Population

BACKGROUND

Low back pain is a condition present during both adulthood and adolescence. Adolescents with low back pain may benefit from treatment focused on improving abdominal muscle performance and motor control. The supine double leg lowering test (SDLLT) may be a reliable measure to assess core stability in adults, but adolescent performance on the SDLLT has not yet been established in the literature.

PURPOSE

To examine performance on the SDLLT in healthy adolescents ages 13 to 18 years and describe influences of gender, age, body mass index, and participation in sport.

STUDY DESIGN

Cross-Sectional Study.

METHODS

Four licensed physical therapists administered the SDLLT with a Stabilizer pressure biofeedback cuff and inclinometer in 90 adolescents without low back pain (females = 41, males = 49) from three schools in a mid-western metropolitan area. Descriptive statistics, independent sample t-tests, two-way analysis of variance, and Pearson correlation coefficients were utilized to analyze the data.

RESULTS

Average SDLLT score was 72.36 +/- 12.54 degrees. A significant difference between SDLLT score was present between genders with males performing better than females. No interactions between performance and involvement in sport were demonstrated.

CONCLUSIONS

Female and male adolescents appear to perform differently on the SDLLT with a stabilizer and appear to perform worse than scores recorded for adults. The SDLLT may be used to measure motor control in adolescents, but clinicians should utilize age-appropriate data for clinical decision making.

LEVELS OF EVIDENCE

Level 2c.

3D Stereophotogrammetric Quantitative Evaluation of Posture and Spine Proprioception in Subacute and Chronic Nonspecific Low Back Pain

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.

Relationship between gait complexity and pain attention in chronic low back pain

ABSTRACT

Clinical models of chronic low back pain (cLBP) highlight the role of excessive attention to pain and kinesiophobia on the origin of disability. At the motor control level, various mechanisms are involved in the impairments observed in patients with cLBP. We aimed to assess the role of maladaptative attentional behaviors by using a complex systems approach and a visual display as a distraction during walking. Sixteen patients with cLBP with no previous surgery or significant leg pain and 16 healthy matched controls were included. Patients walked on a treadmill at preferred walking speed with and without distraction. Stride time (ST) fractal complexity was assessed using detrended fluctuation analysis. A two-way analysis of variance with repeated measures on distraction was performed on fractal exponents. We found a significant group × distraction interaction effect on fractal complexity of ST series (F(1,30) = 9.972, P = 0.004). Post hoc analysis showed that, without distraction, patients with cLBP had significantly lower ST complexity than controls, but when distracted, they regained gait complexity, recovering the level of controls. Our results suggest that excessive attention to pain causes loss of complexity and adaptability in cLBP and explain alterations of motor control with pain. Fractal analysis seems to be a promising method to explore movement variability and individual adaptability in musculoskeletal disorders.

Associations of low-back pain and pain-related cognitions with lumbar movement patterns during repetitive seated reaching

BACKGROUND

Development of more effective interventions for nonspecific chronic low back pain (LBP), requires a robust theoretical framework regarding mechanisms underlying the persistence of LBP. Altered movement patterns, possibly driven by pain-related cognitions, are assumed to drive pain persistence, but cogent evidence is missing.

AIM

To assess variability and stability of lumbar movement patterns, during repetitive seated reaching, in people with and without LBP, and to investigate whether these movement characteristics are associated with pain-related cognitions.

METHODS

60 participants were recruited, matched by age and sex (30 back-healthy and 30 with LBP). Mean age was 32.1 years (SD13.4). Mean Oswestry Disability Index-score in LBP-group was 15.7 (SD12.7). Pain-related cognitions were assessed by the 'Pain Catastrophizing Scale' (PCS), 'Pain Anxiety Symptoms Scale' (PASS) and the task-specific 'Expected Back Strain' scale(EBS). Participants performed a seated repetitive reaching movement (45 times), at self-selected speed. Lumbar movement patterns were assessed by an optical motion capture system recording positions of cluster markers, located on the spinous processes of S1 and T8. Movement patterns were characterized by the spatial variability (meanSD) of the lumbar Euler angles: flexion-extension, lateral-bending, axial-rotation, temporal variability (CyclSD) and local dynamic stability (LDE). Differences in movement patterns, between people with and without LBP and with high and low levels of pain-related cognitions, were assessed with factorial MANOVA.

RESULTS

We found no main effect of LBP on variability and stability, but there was a significant interaction effect of group and EBS. In the LBP-group, participants with high levels of EBS, showed increased MeanSD_{lateral-bending} (p = 0.004, η² = 0.14), indicating a large effect. MeanSD_{axial-rotation} approached significance (p = 0.06).

SIGNIFICANCE

In people with LBP, spatial variability was predicted by the task-specific EBS, but not by the general measures of pain-related cognitions. These results suggest that a high level of EBS is a driver of increased spatial variability, in participants with LBP.

The effect of motor control training according to the Kinetic Control concept on the back pain of female football players

BACKGROUND

Due to a significant burden associated with training sessions and matches, female football players often suffer from lumbar pain. Physical exercise is considered an effective form of therapy for this condition. The exercises in the Kinetic Control concept are one of the forms of motor control training.

OBJECTIVE

The aim of the study was to evaluate the effectiveness of motor control training according to the Kinetic Control concept on the level of lumbar spine pain, degree of disability, functional level and load distribution of lower limbs in football players.

METHODS

The study included 18 football players, randomly divided into two study groups: A - female players implementing their training plan with additional Kinetic Control training (n= 9) and B (control) - female players implementing their training plan only (n= 9). Pain intensity was measured using Visual Analogue Scale (VAS) and Laitinen's questionnaire. Functional disability was assessed using Oswestry Disability Index (ODI) and Back Pain Functional Scale (BPFS). The asymmetry index was assessed in a balance test with open and closed eyes and a countermovement jump (CMJ).

RESULTS

There was a significant statistical difference between the groups (p< 0.05) in measurements using VAS, ODI and BPFS, in favor of group A. Asymmetry index values in tests on the dynamometer platform did not differ significantly between the groups (p> 0.05). A statistically significant correlation was found between the asymmetry index score in the closed-eye balance test (r= 0.567, p= 0.049) and the CMJ landing phase (r= 0.641, p= 0.033), and the level of pain measured using VAS.

CONCLUSIONS

Motor control training in the Kinetic Control concept reduced the pain symptoms of the lumbar spine and the degree of disability and increased the functional level in football female players.

Individuals with recurrent low back pain exhibit further altered frontal plane trunk control in remission than when in pain

BACKGROUND

Movement alterations due to low back pain (LBP) could lead to long-term adverse consequences if they do not resolve after symptoms subside. This study aims to determine if altered trunk control associated with recurrent low back pain persists beyond symptom duration.

METHODS

Twenty young adults with recurrent LBP were tested once during an LBP episode and once in symptom remission, and twenty matched back-healthy participants served as controls. Participants walked on a treadmill with five prescribed step widths (0.33, 0.67, 1, 1.33, 1.67 × preferred step width). Motion capture and surface electromyography were used to record trunk kinematics and muscle activation. Thorax-pelvis coordination was calculated using vector coding, and longissimus activation and co-activation were analyzed.

FINDINGS

Young adults with recurrent LBP exhibited a "looser" trunk control strategy in the frontal plane during gait that was persistent regardless of pain status across multiple step widths compared to controls. The looser trunk control was demonstrated by a greater pelvis-only, less thorax-only coordination pattern, and decreased bilateral longissimus co-activation in individuals with recurrent LBP compared to controls. The looser trunk control strategy was further amplified when individuals were in symptom remission and exhibited greater trunk excursion and reduced in-phase coordination in the frontal plane.

INTERPRETATION

The amplification of aberrant movement during symptom remission may suggest that movement patterns or anatomical factors existing prior to the tested painful episode underlie altered trunk control in individuals with recurrent LBP. The symptom remission period of recurrent LBP may be a critical window into clinical evaluation and treatment.

The contemporary model of vertebral column joint dysfunction and impact of high-velocity, low-amplitude controlled vertebral thrusts on neuromuscular function

Purpose

There is growing evidence that vertebral column function and dysfunction play a vital role in neuromuscular control. This invited review summarises the evidence about how vertebral column dysfunction, known as a central segmental motor control (CSMC) problem, alters neuromuscular function and how spinal adjustments (high-velocity, low-amplitude or HVLA thrusts directed at a CSMC problem) and spinal manipulation (HVLA thrusts directed at segments of the vertebral column that may not have clinical indicators of a CSMC problem) alters neuromuscular function.

Methods

The current review elucidates the peripheral mechanisms by which CSMC problems, the spinal adjustment or spinal manipulation alter the afferent input from the paravertebral tissues. It summarises the contemporary model that provides a biologically plausible explanation for CSMC problems, the manipulable spinal lesion. This review also summarises the contemporary, biologically plausible understanding about how spinal adjustments enable more efficient production of muscular force. The evidence showing how spinal dysfunction, spinal manipulation and spinal adjustments alter central multimodal integration and motor control centres will be covered in a second invited review.

Results

Many studies have shown spinal adjustments increase voluntary force and prevent fatigue, which mainly occurs due to altered supraspinal excitability and multimodal integration. The literature suggests physical injury, pain, inflammation, and acute or chronic physiological or psychological stress can alter the vertebral column’s central neural motor control, leading to a CSMC problem. The many gaps in the literature have been identified, along with suggestions for future studies.

Conclusion

Spinal adjustments of CSMC problems impact motor control in a variety of ways. These include increasing muscle force and preventing fatigue. These changes in neuromuscular function most likely occur due to changes in supraspinal excitability. The current contemporary model of the CSMC problem, and our understanding of the mechanisms of spinal adjustments, provide a biologically plausible explanation for how the vertebral column’s central neural motor control can dysfunction, can lead to a self-perpetuating central segmental motor control problem, and how HVLA spinal adjustments can improve neuromuscular function.

Spinal movement variability associated with low back pain: A scoping review

Objective

To identify suggestions for future research on spinal movement variability (SMV) in individuals with low back pain (LBP) by investigating (1) the methodologies and statistical tools used to assess SMV; (2) characteristics that influence the direction of change in SMV; (3) the methodological quality and potential biases in the published studies; and (4) strategies for optimizing SMV in LBP patients.

Methods

We searched literature databases (CENTRAL, Medline, PubMed, Embase, and CINAHL) and comprehensively reviewed the relevant papers up to 5 May 2020. Eligibility criteria included studies investigating SMV in LBP subjects by measuring trunk angle using motion capture devices during voluntary repeated trunk movements in any plane. The Newcastle-Ottawa risk of bias tool was used for data quality assessment. Results were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

Results

Eighteen studies were included: 14 cross-sectional and 4 prospective studies. Seven linear and non-linear statistical tools were used. Common movement tasks included trunk forward bending and backward return, and object lifting. Study results on SMV changes associated with LBP were inconsistent. Two of the three interventional studies reported changes in SMV, one of which was a randomized controlled trial (RCT) involving neuromuscular exercise interventions. Many studies did not account for the potential risk of selection bias in the LBP population.

Conclusion

Designers of future studies should recognize that each of the two types of statistical tools assesses functionally different aspects of SMV. Future studies should also consider dividing participants into subgroups according to LBP characteristics, as three potential subgroups with different SMV characteristics were proposed in our study. Different task demands also produced different effects. We found preliminary evidence in a RCT that neuromuscular exercises could modify SMV, suggesting a rationale for well-designed RCTs involving neuromuscular exercise interventions in future studies.