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

The Effect of Cautionary Versus Resiliency Spine Education on Maximum Deadlift Performance and Back Beliefs: A Randomized Control Trial

ABSTRACT

Scott, KM, Kreisel, BR, Florkiewicz, EM, Crowell, MS, Morris, JB, McHenry, PA, and Benedict, TM. The effect of cautionary versus resiliency spine education on maximum deadlift performance and back beliefs: A randomized control trial. J Strength Cond Res 38(7): e341-e348, 2024-The purpose of this study was to determine the effect of cautionary information about the spine vs. a message of spine resiliency on maximum deadlift (MDL) performance and beliefs regarding the vulnerability of the spine. This cluster randomized control trial involved 903 military new cadets (n = 903) during their mandatory fitness test in cadet basic training (mean age 18.3 years, body mass index 23.8 kg·m-2, 22% female). Subjects were cluster randomized to 3 groups. The cautionary group received a message warning them to protect their backs while deadlifting, the resiliency group received a message encouraging confidence while deadlifting, and the control group received the standardized Army deadlift education only. The outcome measures were MDL weight lifted and perceived spine vulnerability. Significance was set at alpha ≤0.05. There were no between-group differences in weight lifted (p=0.40). Most subjects believed that the spine is vulnerable to injury. Three times as many subjects who received the resiliency education improved their beliefs about the vulnerability of their spines compared with those receiving the cautionary education (p<0.001). This study demonstrated the potential for brief resiliency education to positively influence beliefs about spine vulnerability, whereas cautionary education did not impair performance.

How do people with chronic low back pain perceive specific and general exercise? A mixed methods survey

PURPOSE

Exercise prescriptions for chronic low back pain (CLBP) often utilize reductionistic, trunk-focused exercise aimed at addressing proposed pain mechanisms. It is unknown if the use of these trunk-focused exercises imply beliefs to people with CLBP about the rationale for their use (e.g., etiology), even without concurrent biomedical narratives. This study aimed to explore people's perceptions of specific and general exercise without an accompanying narrative when experiencing CLBP.

METHODS

An anonymous online survey was distributed. Mixed methods were utilized for analysis. Six-point Likert scales categorized people's beliefs about individual exercises. Open-ended questions were used to gather further beliefs which were then coded into themes.

RESULTS

People with CLBP perceived specific exercise as more beneficial than general exercise. Eight themes and five subthemes were defined. A high volume of positive beliefs were centered around strengthening the low back and abdominal musculature, emphasizing the importance of correct technique. Negative beliefs were held against spinal flexion and external load. Both positive and negative beliefs were underpinned by spinal/pelvic stability being important as well as certain exercises being achievable or not.

CONCLUSION

This study demonstrated that people with CLBP consider specific exercises to be more beneficial than general exercises for CLBP. Specific exercises irrespective of an accompanying narrative can imply meaning about the intent of an exercise. Understanding this requires practitioners to be mindful when prescribing and communicating exercise.

An Exploration of Low Back Beliefs of Male Pre-Professional and Professional Dancers

BACKGROUND

Globally, male dancers are affected by low back pain (LBP) up to 2.5 times more than female dancers. While female dancers' beliefs around LBP and dance-specific low back movements exist, no research has explored male dancers' beliefs. This study aimed to (1) examine the low back beliefs of Australian male professional and pre-professional dancers, and (2) determine if beliefs toward common low back movements and lifting differed when current LBP or history of disabling LBP (DLBP) were considered.

METHODS

40 male dancers (mean age [SD] 26.9 years [7.9]) from a range of dance backgrounds (all participating in ballet) were recruited to complete a cross-sectional survey comprising a beliefs questionnaire considering dance-specific movement and lifting tasks, the Back Pain Attitudes Questionnaire (Back-PAQ) and the Athletic Fear Avoidance Questionnaire (AFAQ). Primary analysis included initial descriptives, a repeated measures ANOVA for movement-specific beliefs and visual thematic analysis for written responses within the belief's questionnaire. Secondary subgroup analysis included independent T-tests for those with/without current LBP and those with/without a history of DLBP.

RESULTS

Fourteen dancers reported current LBP and 30 reported a history of DLBP. Dancers held generally negative beliefs toward the low back (Back-PAQ mean 123.1 ± 9.7) with neither subgroup demonstrating significant between-group difference (P < .05). Dance-specific flexion movements were seen as safer than extension movements (P < .05), and more extended-spine lifting was seen as safer than more flexed-spine lifting (P < .05). Dancers experiencing current LBP held less positive beliefs surrounding some dance-specific movements.

CONCLUSIONS

Dancers hold negative general beliefs toward the low back irrespective of current or historical DLBP, however their beliefs surrounding dance-specific movements were relatively positive. Dancers' beliefs surrounding some movements were affected by the presence of current LBP, in particular an arabesque and a fish dive.

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.

Conventional video recordings dependably quantify whole-body lifting strategy using the Stoop-Squat-Index: A methods comparison against motion capture and a reliability study

Whole-body lifting strategies could be derived from conventional video recordings using the Stoop-Squat-Index, which quantifies the ratio between trunk forward lean and lower extremity joint flexion from 0 (full squat) to 100 (full stoop). The purpose of this study was to compare Stoop-Squat-Indices derived from conventional video recordings to those from a three-dimensional marker-based motion capture system and to evaluate interrater and intrarater reliability of the video-based approach. Thirty healthy participants lifted a 5-kg box under different conditions (freestyle, squat, stoop). Kinematic data were recorded using a Vicon motion capture system (serving as reference standard) and an iPad camera. Stoop-Squat-Indices over the entire lifting cycle were derived separately from both approaches. Agreement was assessed using mean differences (video minus motion capture) and limits of agreement. Reliability was investigated by calculating intraclass correlation coefficients (ICC) and minimal detectable changes (MDC) over the course of the lifting cycle. Systematic errors were identified with Statistical Parametric Mapping-based T-tests. Systematic errors between the video-based and the motion capture-based approach were observed among all conditions. Mean differences in Stoop-Squat-Indices over the lifting cycle ranged from -6.9 to 3.2 (freestyle), from -1.8 to 5.3 (squat) and from -2.8 to -1.1 (stoop). Limits of agreement were lower when the box was close to the floor, and higher towards upright standing. Reliability of the video-based approach was excellent for most of the lifting cycle, with ICC above 0.995 and MDC below 3.5. These findings support using a video-based assessment of Stoop-Squat-Indices to quantify whole-body lifting strategy in field.

Classification of the Pathological Range of Motion in Low Back Pain Using Wearable Sensors and Machine Learning

Low back pain (LBP) is a highly common musculoskeletal condition and the leading cause of work absenteeism. This project aims to develop a medical test to help healthcare professionals decide on and assign physical treatment for patients with nonspecific LBP. The design uses machine learning (ML) models based on the classification of motion capture (MoCap) data obtained from the range of motion (ROM) exercises among healthy and clinically diagnosed patients with LBP from Imbabura-Ecuador. The following seven ML algorithms were tested for evaluation and comparison: logistic regression, decision tree, random forest, support vector machine (SVM), k-nearest neighbor (KNN), multilayer perceptron (MLP), and gradient boosting algorithms. All ML techniques obtained an accuracy above 80%, and three models (SVM, random forest, and MLP) obtained an accuracy of >90%. SVM was found to be the best-performing algorithm. This article aims to improve the applicability of inertial MoCap in healthcare by making use of precise spatiotemporal measurements with a data-driven treatment approach to improve the quality of life of people with chronic LBP.

Societal beliefs about pain may be more balanced than previously thought. Results of the Guernsey pain survey

BACKGROUND

Musculoskeletal pain is multidimensional and associated with significant societal impact. Persistent or chronic pain is a public health priority. A step towards high-value care is a contemporary understanding of pain. While pain-related knowledge has been examined in specific conditions (e.g. neck pain) knowledge of the public's broader understanding regarding musculoskeletal pain per se, warrants investigation. This study examined the public's knowledge and beliefs regarding musculoskeletal pain and pain management.

METHODS

This observational cohort study was conducted in Guernsey (January 2019-February 2020). Participants (n = 1656; 76.0% female) completed an online questionnaire capturing: demographics, pain experience, work absenteeism, understanding of pain and pain management, multidimensional influences, physical activity, pain catastrophising and healthcare decision-making. Statements were deemed true/false/equivocal and mapped to biopsychosocial/biomedical/neutral perspectives based upon contemporary literature. Descriptive statistics were analysed for each statement. Participants' responses were examined for alignment to a contemporary viewpoint and themes within responses derived using a semi-quantitative approach modelled on direct content analysis. Comparisons between participants with/without pain were examined (χ2-squared/Wilcoxon Rank Sum test).

RESULTS

Within the cohort 83.6% reported currently experiencing pain. The overarching theme was perspectives that reflected both biomedical and contemporary, multidimensional understandings of pain. Sub-themes included uncertainty about pain persistence and evidence-based means to reduce recurrence, and reliance upon healthcare professionals for guiding decision-making. Compared to those with pain, those without had a greater belief that psychological interventions may help and lower pain catastrophising.

CONCLUSIONS

Participants' understanding of pain demonstrated both biomedical and multidimensional pain understanding consistent with elements of a contemporary understanding of pain.

Optimizing Resistance Training Technique to Maximize Muscle Hypertrophy: A Narrative Review

Regimented resistance training (RT) has been shown to promote increases in muscle size. When engaging in RT, practitioners often emphasize the importance of appropriate exercise technique, especially when trying to maximize training adaptations (e.g., hypertrophy). This narrative review aims to synthesize existing evidence on what constitutes proper RT exercise technique for maximizing muscle hypertrophy, focusing on variables such as exercise-specific kinematics, contraction type, repetition tempo, and range of motion (ROM). We recommend that when trying to maximize hypertrophy, one should employ a ROM that emphasizes training at long muscle lengths while also employing a repetition tempo between 2 and 8 s. More research is needed to determine whether manipulating the duration of either the eccentric or concentric phase further enhances hypertrophy. Guidelines for body positioning and movement patterns are generally based on implied theory from applied anatomy and biomechanics. However, existing research on the impact of manipulating these aspects of exercise technique and their effect on hypertrophy is limited; it is therefore suggested that universal exercise-specific kinematic guidelines are followed and adopted in accordance with the above recommendations. Future research should investigate the impact of stricter versus more lenient exercise technique variations on hypertrophy.

Manual patient handling in the healthcare setting: a scoping review

BACKGROUND

Manual patient handling is the most frequently reported risk factor for work related musculoskeletal disorders in healthcare. Patient handling tasks are routinely performed manually without assistive devices and can create awkward postures and high loads for nurses and allied health professionals (AHPs). However, AHPs, notably physiotherapists, also utilize therapeutic handling to facilitate patient movement during rehabilitation.

OBJECTIVES

To comprehensively map the literature surrounding manual patient handling (without assistive devices) by healthcare practitioners.

METHODS

AMED, CINAHL, MEDLINE, SPORTDiscus, and EMBASE databases were searched. Grey literature was sourced from Google Scholar, EThOS, Open Grey, Health and Safety Executive, National Institute for Occupational Safety and Health and Work Safe Australia. Literature published in English between 2002 and 2021 was included.

RESULTS

Forty-nine records were included: 36 primary research studies, 1 systematic review and 12 'other' including narrative and government reports. Primary research was predominantly observational cross-sectional (n = 21). The most common settings included laboratories (n = 13) and hospitals (n = 13). Seven research questions were identified, with patient handling practices (n = 13) the most common. Nurses formed the largest practitioner population (n = 13) and patients were often simulated (n = 12). Common outcomes included tasks performed (n = 13) and physical demands during patient handling (n = 13).

CONCLUSION AND IMPLICATIONS OF KEY FINDINGS

This comprehensive scoping review identified that most research was observational, investigating nurses in hospitals or laboratories. More research on manual patient handling by AHPs and investigation of the biomechanics involved in therapeutic handling is needed. Further qualitative research would allow for greater understanding of manual patient handling practices within healthcare. CONTRIBUTION OF THE PAPER.

Reducing Back Exertion and Improving Confidence of Individuals with Low Back Pain with a Back Exosuit: A Feasibility Study for Use in BACPAC

OBJECTIVE

Low back pain (LBP) is hallmarked by activity limitations, especially for tasks involving bending. Back exosuit technology reduces low back discomfort and improves self-efficacy of individuals with LBP during bending and lifting tasks. However, the biomechanical efficacy of these devices in individuals with LBP is unknown. This study sought to determine biomechanical and perceptual effects of a soft active back exosuit designed to assist individuals with LBP sagittal plane bending. To understand patient-reported usability and use cases for this device.

METHODS

Fifteen individuals with LBP performed two experimental lifting blocks once with and without an exosuit. Trunk biomechanics were measured by muscle activation amplitudes, and whole-body kinematics and kinetics. To evaluate device perception, participants rated task effort, low back discomfort, and their level of concern completing daily activities.

RESULTS

The back exosuit reduced peak back extensor: moments by 9%, and muscle amplitudes by 16% when lifting. There were no changes in abdominal co-activation and small reductions maximum trunk flexion compared to lifting without an exosuit. Participants reported lower task effort, back discomfort, and concern about bending and lifting with an exosuit compared to without.

CONCLUSIONS

This study demonstrates a back exosuit not only imparts perceptual benefits of reduced task effort, discomfort, and increased confidence in individuals with LBP but that it achieves these benefits through measurable biomechanical reductions in back extensor effort. The combined effect of these benefits implies back exosuits might be a potential therapeutic aid to augment physical therapy, exercises, or daily activities.

An exploration of low back pain beliefs in a Northern America based general population

BACKGROUND

Prior research has demonstrated that people across different populations hold beliefs about low back pain (LBP) that are inconsistent with current evidence. Qualitative research is needed to explore current LBP beliefs in Northern America (NA).

OBJECTIVES

We conducted a primarily qualitative cross-sectional online survey to assess LBP beliefs in a NA population (USA and Canada).

METHODS

Participants were recruited online using social media advertisements targeting individuals in NA over the age of 18 with English speaking and reading comprehension. Participants answered questions regarding the cause of LBP, reasons for reoccurrence or persistence of LBP, and sources of these beliefs. Responses were analyzed using conventional (inductive) content analysis.

RESULTS/FINDINGS

62 participants were included with a mean age of 47.6 years. Most participants reported multiple causes for LBP as well as its persistence and reoccurrence, however, these were biomedically focused with minimal to no regard for psychological or environmental influences. The primary cited source of participants' beliefs was healthcare professionals.

CONCLUSIONS

Our findings align with prior research from other regions, demonstrating a need for updating clinical education and public messaging about the biopsychosocial nature of LBP.

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.

Feedback on Trunk Movements From an Electronic Game to Improve Postural Balance in People With Nonspecific Low Back Pain: Pilot Randomized Controlled Trial

Background

Postural balance is compromised in people with low back pain, possibly by changes in motor control of the trunk. Augmenting exercising interventions with sensor-based feedback on trunk posture and movements might improve postural balance in people with low back pain.

Objective

We hypothesized that exercising with feedback on trunk movements reduces sway in anterior-posterior direction during quiet standing in people with low back pain. Secondary outcomes were lumbar spine and hip movement assessed during box lift and waiter bow tasks, as well as participant-reported outcomes. Adherence to the exercising intervention was also examined.

Methods

A randomized controlled trial was conducted with the intervention group receiving unsupervised home exercises with visual feedback using the Valedo Home, an exergame based on 2 inertial measurement units. The control group received no intervention. Outcomes were recorded by blinded staff during 4 visits (T1-T4) at University Hospital Zurich. The intervention group performed 9 sessions of 20 minutes in the 3 weeks between T2 and T3 and were instructed to exercise at their own convenience between T3 and T4. Postural balance was assessed on a force platform. Lumbar spine and hip angles were obtained from 3 inertial measurement units. The assessments included pain intensity, disability, quality of life, and fear of movement questionnaires.

Results

A total of 32 participants with nonspecific low back pain completed the first assessment T1, and 27 (84%) participants were randomized at T2 (n=14, 52% control and n=13, 48% intervention). Intention-to-treat analysis revealed no significant difference in change in anterior-posterior sway direction during the intervention period with a specified schedule (T2-T3) between the groups (W=99; P=.36; r=0.07). None of the outcomes showed significant change in accordance with our hypotheses. The intervention group completed a median of 61% (55/90; range 2%-99%) of the exercises in the predefined training program. Adherence was higher in the first intervention period with a specified schedule.

Conclusions

The intervention had no significant effect on postural balance or other outcomes, but the wide range of adherence and a limited sample size challenged the robustness of these conclusions. Future work should increase focus on improving adherence to digital interventions.

Trial Registration

ClinicalTrials.gov NCT04364243; https://clinicaltrials.gov/ct2/show/NCT04364243

International Registered Report Identifier (IRRID)

RR2-10.2196/26982

An investigation of implicit bias about bending and lifting

OBJECTIVES

Previous studies in a high-income country have demonstrated that people with and without low back pain (LBP) have an implicit bias that bending and lifting with a flexed lumbar spine is dangerous. These studies present two key limitations: use of a single group per study; people who recovered from back pain were not studied. Our aims were to evaluate: implicit biases between back posture and safety related to bending and lifting in people who are pain-free, have a history of LBP or have current LBP in a middle-income country, and to explore correlations between implicit and explicit measures within groups.

METHODS

Exploratory cross-sectional study including 174 participants (63 pain-free, 57 with history of LBP and 54 with current LBP). Implicit biases between back posture and safety related to bending and lifting were assessed with the Implicit Association Test (IAT). Participants completed paper-based (Bending Safety Belief [BSB]) and online questionnaires (Tampa Scale of Kinesiophobia; Back Pain Attitudes Questionnaire).

RESULTS

Participants displayed significant implicit bias between images of round-back bending and lifting and words representing "danger" (IATD-SCORE: Pain-free group: 0.56 (IQR=0.31-0.91; 95% CI [0.47, 0.68]); history of LBP group: 0.57 (IQR=0.34-0.84; 95% CI [0.47, 0.67]); current LBP group: 0.56 (IQR=0.24-0.80; 95% CI [0.39, 0.64])). Explicit measures revealed participants hold unhelpful beliefs about the back, perceiving round-back bending and lifting as dangerous (BSBthermometer: Pain-free group: 8 (IQR=7-10; 95% CI [7.5, 8.5]); history of LBP group: 8 (IQR=7-10; 95% CI [7.5, 9.0]); current LBP group: 8.5 (IQR=6.75-10; [7.5, 9.0])). There was no correlation between implicit and explicit measures within the groups.

CONCLUSIONS

In a middle-income country, people with and without LBP, and those who recovered from LBP have an implicit bias that round-back bending and lifting is dangerous.

The Stoop-Squat-Index: a simple but powerful measure for quantifying whole-body lifting behavior

Background

Most of the studies evaluating lifting behavior only focus on very localized parameters such as lumbar spine flexion, while evaluations of whole-body strategies are largely lacking. To enable relatively simple evaluations of whole-body strategies, this study aimed at developing a novel index for quantifying the stoop-squat behavior, and to establish normative values of the index for healthy pain-free adults.

Methods

A novel index, the Stoop-Squat-Index, was developed, which describes the proportion between trunk forward lean and lower extremity joint flexion, with possible values ranging from 0 (full squat lifting) to 100 (full stoop lifting). To enable the interpretation of the index in a real-life setting, normative values for lifting a moderately-weighted object (15-kg-box) with a full squat and a full stoop technique were established using motion capture data from 30 healthy pain-free individuals that underwent motion analysis of squat and stoop lifting in the context of a previously conducted study.

Results

The results showed mean index values of lower than 30 and higher than 90 for the most relevant phases of the squat and stoop movements, respectively, with mean index values differing significantly from each other for the full duration of the lifting phases.

Conclusions

The main advantages of the index are that it is simple to calculate and can not only be derived from motion capture data but also from conventional video recordings, which enables large-scale in-field measurements with relatively low expenditure. When used in combination with lumbar spine flexion measurements, the index can contribute important information, which is necessary for comprehensively evaluating whole-body lifting strategies and to shed more light on the debate over the connection between lifting posture and back complaints.

What Are the Physical Demands of Sexual Intercourse? A Systematic Review of the Literature

The aim of this study was to systematically review the literature investigating the physical demands of sexual intercourse and to synthesize the evidence related to this research topic. Original studies published on PubMed, Scopus, and Web of Science up until April 2020 were examined. The Effective Public Health Practice Project scale was used to assess the methodological quality of each study. Eighteen studies analyzed physical demands during sexual intercourse through the physiological demands (n = 14) and kinematics (n = 4) of sexual intercourse. Sexual intercourse can elicit an energy expenditure of ~ 100 kcal (or ~ 6 metabolic equivalent units, METs) during the activity, mean heart rates between ~ 90 and ~ 130 beats per minute (bpm), and peak heart rates up to ~ 170 bpm. However, these physical demands may vary depending on health status, intercourse position, activity duration, intercourse phase, and sex differences. The movement pattern was cyclic in all positions and the greatest demands in lumbar spine flexion were found in the missionary positions for women. Missionary and side-lying positions elicited the greatest lumbar flexion movement in men. Regarding the movement of the hip joint during sexual intercourse, flexion, abduction, and external rotation mainly characterized the woman's movement while external rotation did so in the man. In conclusion, sexual intercourse may elicit moderate intensity physical demands, but these demands vary depending on contextual variables. In addition, not only studies combining physiological and kinematic analyses are necessary but also more high-quality studies need to be published in order to have a better understanding of the physical demands of sexual intercourse.

A vision for the future of wearable sensors in spine care and its challenges: narrative review

OBJECTIVE

This review aimed to: (I) provide a brief overview of some topical areas of current literature regarding applications of wearable sensors in the management of low back pain (LBP); (II) present a vision for a future comprehensive system that integrates wearable sensors to measure multiple parameters in the real world that contributes data to guide treatment selection (aided by artificial intelligence), uses wearables to aid treatment support, adherence and outcome monitoring, and interrogates the response of the individual patient to the prescribed treatment to guide future decision support for other individuals who present with LBP; and (III) consider the challenges that will need to be overcome to make such a system a reality.

BACKGROUND

Advances in wearable sensor technologies are opening new opportunities for the assessment and management of spinal conditions. Although evidence of improvements in outcomes for individuals with LBP from the use of sensors is limited, there is enormous future potential.

METHODS

Narrative review and literature synthesis.

CONCLUSIONS

Substantial research is underway by groups internationally to develop and test elements of this system, to design innovative new sensors that enable recording of new data in new ways, and to fuse data from multiple sources to provide rich information about an individual's experience of LBP. Together this system, incorporating data from wearable sensors has potential to personalise care in ways that were hitherto thought impossible. The potential is high but will require concerted effort to develop and ultimately will need to be feasible and more effective than existing management.

A comparison of augmented feedback and didactic training approaches to reduce spine motion during occupational lifting tasks

Manual handling training may be improved if it relied on the provision of individualized, augmented feedback about key movement features. The purpose of this study was to compare the reduction in sagittal spine motion during manual lifting tasks following two training approaches: didactic (DID) and augmented feedback (AUG). Untrained participants (n = 26) completed lifting tests (box, medication bag, and paramedic backboard) and a randomly-assigned intervention involving 50 practice box lifts. Lifting tests were performed immediately before and after training, and one-week after interventions. Both groups exhibited reductions in spine motions immediately and one-week after the interventions. However, the AUG intervention group elicited significantly greater reductions in 5 of 12 between-group comparisons (3 tasks × 4 spine motion variables). The results of the current study support the use of augmented feedback-based approaches to manual handling training over education-based approaches.

The Validity of Wireless Earbud-Type Wearable Sensors for Head Angle Estimation and the Relationships of Head with Trunk, Pelvis, Hip, and Knee during Workouts

The present study was performed to investigate the validity of a wireless earbud-type inertial measurement unit (Ear-IMU) sensor used to estimate head angle during four workouts. In addition, relationships between head angle obtained from the Ear-IMU sensor and the angles of other joints determined with a 3D motion analysis system were investigated. The study population consisted of 20 active volunteers. The Ear-IMU sensor measured the head angle, while a 3D motion analysis system simultaneously measured the angles of the head, trunk, pelvis, hips, and knees during workouts. Comparison with the head angle measured using the 3D motion analysis system indicated that the validity of the Ear-IMU sensor was very strong or moderate in the sagittal and frontal planes. In addition, the trunk angle in the frontal plane showed a fair correlation with the head angle determined with the Ear-IMU sensor during a single-leg squat, reverse lunge, and standing hip abduction; the correlation was poor in the sagittal plane. Our results indicated that the Ear-IMU sensor can be used to directly estimate head motion and indirectly estimate trunk motion.

Lifting Techniques: Why Are We Not Using Evidence To Optimize Movement?

Lifting something off the ground is an essential task and lifting is a documented risk factor for low back pain (LBP). The standard lifting techniques are stoop (lifting with your back), squat (lifting with your legs), and semi-squat (midway between stoop and squat). Most clinicians believe the squat technique is optimal; however, training on squat lifting does not prevent LBP and utilizing greater lumbar flexion (i.e. stoop) when lifting is not a risk factor for LBP. The disconnect between what occurs in clinical practice and what the evidence suggests has resulted in ongoing debate. Clinicians must ask the right questions in order to apply the evidence appropriately. A proposed clinical framework of calm tissue down, build tissue up, improve work capacity can be used to determine which lifting technique is optimal for a patient at any given time. When applying this clinical framework, clinicians should consider metabolic, biomechanical, physical stress tolerance, and pain factors in order to address the movement system. For example, stoop lifting is more metabolically efficient and less challenging to the cardiopulmonary system. There may be few biomechanical differences in spinal postures and gross loads on the lumbar spine between stoop, squat, and semi-squat lifting; however, each lift has distinct kinematic patterns that affects muscle activation patterns, and ultimately the movement system. Clinicians must find the optimal dosage of physical stress to address all aspects of the movement system to minimize the risk of injury. There is no universal consensus on the optimal lifting technique which will satisfy every situation; however, there may be a lifting technique that optimizes movement to achieve a specific outcome. The calm tissue down, build tissue up, improve work capacity framework offers an approach to determine the best lifting technique for an individual patient at any give time.

LEVEL OF EVIDENCE

5.

Wearable Technology to Increase Self-Awareness of Low Back Pain: A Survey of Technology Needs among Health Care Workers

Low back pain (LBP) is a leading contributor to musculoskeletal injury worldwide and carries a high economic cost. The healthcare industry is the most burdened, with nurses, in particular, being highly prone to LBP. Wearable technologies have the potential to address the challenges of monitoring postures that contribute to LBP and increase self-awareness of workplace postures and movements. We aimed to gain insight into workers’ perceptions of LBP and whether they would consider using wearable monitoring technologies to reduce injury risks. We conducted a cross-sectional survey to gather information from a selected population of nurses. Sixty-four participants completed the survey, and data were analyzed with the support of Machine Learning techniques. Findings from this study indicate that the surveyed population (64 nurses) is interested in these new approaches to monitor movement and posture in the workplace. This technology can potentially change the way ergonomic guidelines are implemented in this population.

From Stoop to Squat: A Comprehensive Analysis of Lumbar Loading Among Different Lifting Styles

Lifting up objects from the floor has been identified as a risk factor for low back pain, whereby a flexed spine during lifting is often associated with producing higher loads in the lumbar spine. Even though recent biomechanical studies challenge these assumptions, conclusive evidence is still lacking. This study therefore aimed at comparing lumbar loads among different lifting styles using a comprehensive state-of-the-art motion capture-driven musculoskeletal modeling approach. Thirty healthy pain-free individuals were enrolled in this study and asked to repetitively lift a 15 kg-box by applying 1) a freestyle, 2) a squat and 3) a stoop lifting technique. Whole-body kinematics were recorded using a 16-camera optical motion capture system and used to drive a full-body musculoskeletal model including a detailed thoracolumbar spine. Continuous as well as peak compressive, anterior-posterior shear and total loads (resultant load vector of the compressive and shear load vectors) were calculated based on a static optimization approach and expressed as factor body weight (BW). In addition, lumbar lordosis angles and total lifting time were calculated. All parameters were compared among the lifting styles using a repeated measures design. For each lifting style, loads increased towards the caudal end of the lumbar spine. For all lumbar segments, stoop lifting showed significantly lower compressive and total loads (-0.3 to -1.0BW) when compared to freestyle and squat lifting. Stoop lifting produced higher shear loads (+0.1 to +0.8BW) in the segments T12/L1 to L4/L5, but lower loads in L5/S1 (-0.2 to -0.4BW). Peak compressive and total loads during squat lifting occurred approximately 30% earlier in the lifting cycle compared to stoop lifting. Stoop lifting showed larger lumbar lordosis range of motion (35.9 ± 10.1°) than freestyle (24.2 ± 7.3°) and squat (25.1 ± 8.2°) lifting. Lifting time differed significantly with freestyle being executed the fastest (4.6 ± 0.7 s), followed by squat (4.9 ± 0.7 s) and stoop (5.9 ± 1.1 s). Stoop lifting produced lower total and compressive lumbar loads than squat lifting. Shear loads were generally higher during stoop lifting, except for the L5/S1 segment, where anterior shear loads were higher during squat lifting. Lifting time was identified as another important factor, considering that slower speeds seem to result in lower loads.

Evaluating a wearable biofeedback device for reducing end-range sagittal lumbar spine flexion among home caregivers

Caregivers who work in the home environment are at risk of back injury due to the awkward postures they have to adopt while providing care. Real-time biofeedback provided by a recently developed wearable device (PostureCoach) may be able to reduce this risk. The effectiveness of a two-day training intervention (including PostureCoach and an educational video) was evaluated for its ability to decrease the amount of time spent in end-range spine flexion. Twenty novice caregivers repeated a series of simulated care tasks. Real-time auditory biofeedback was provided to the intervention group (n = 10) when participants' sagittal lumbar spine flexion exceeded a preset threshold during training trials. Participants in the control group (n = 10) received no feedback. Participants repeated the tasks again two weeks and two months post-intervention. The intervention group maintained decreased end-range (80th and 95th percentile) spine flexion compared to controls at both post-intervention time points.

The relationship between readiness to change pain-related exercise participation and perceived work ability: a cross-sectional study of factory workers

BACKGROUND

Healthy lifestyle behaviours are associated with protection against health disorders and pain. Exercise participation is one such behaviour, associated with improved outcomes in those experiencing pain. Musculoskeletal pain is highly prevalent in the workplace, particularly in factory workers and associated loss of work function is recognised as having a great impact on individuals, society and the economy. A worker's 'readiness to change pain behaviour' is an important factor to consider in achieving a healthy lifestyle behaviour and potentially improved function. This study aimed to examine the relationship between a cohort of factory workers 'readiness to change pain behaviour' such as exercise and their 'perceived work ability'.

METHODS

A cross-sectional study design was used to establish the relationship between 'readiness to change pain behaviours' and 'perceived work ability'. The Multidimensional Pain Related Change Questionnaire 2 (MPRCQ2) was used to measure readiness to change various pain behaviours including exercise. The Work Ability Index (WAI) was used to assess 'perceived work ability'. Seventy-five factory workers, aged over 18 (66 male, 9 female) were recruited using convenience sampling between September-November 2019. Correlation and multiple regression were used for statistical analysis.

RESULTS

Mean WAI, MPRCQ2 and MPRCQ2 exercise component were 41.89 (SD 5.28), 4.26 (SD 1.01) and 4.40 (SD 1.69). MPRCQ2 and MPRCQ2 exercise component were not significant predictors of WAI in factory workers (F (2, 72) = 2.17, p > 0.001). There was no significant relationship between MPRCQ2 and WAI (rs = .09, p > .05). However, there was a significant positive relationship between MPRCQ2 exercise component and WAI (rs = .23, p < .05).

CONCLUSIONS

This study suggests that readiness to change pain-related exercise participation has a positive association with 'perceived work ability'. Further research should explore the causal relationship and consider strength training as a specific type of exercise.

Body-powered variable impedance: An approach to augmenting humans with a passive device by reshaping lifting posture

The movement patterns appropriate for exercise and manual labor do not always correspond to what people instinctively choose for better comfort. Without expert guidance, people can even increase the risk of injury by choosing a comfortable posture rather than the appropriate one, notably when lifting objects. Even in situations where squatting is accepted as a desirable lifting strategy, people tend to choose the more comfortable strategy of stooping or semisquatting. The common approach to correcting lifting posture, immobilizing vulnerable joints via fixation, is insufficient for preventing back injuries sustained from repetitive lifting. Instead, when lifting small but heavy objects, the entire kinetic chain should cooperate to achieve a series of squat-lifting patterns. Inspired by the observation that force fields affect the coordination of voluntary human motion, we devised a passive exosuit embedded with a body-powered variable-impedance mechanism. The exosuit adds impedance to the human joints according to how far the wearer's movement is from the squat-lifting trajectories so that it hinders stooping but facilitates squatting. In an experiment that entailed lifting a small 10-kg box, 10 first-time users changed their voluntary lifting motion closer to squatting on average. Simulation results based on recorded kinematic and kinetic data showed that this postural change reduced the compression force, shear force, and moment on the lumbosacral joint. Our work demonstrates the potential of using an exosuit to help people move in a desirable manner without requiring a complicated, bulky mechanical system.

Exploring lumbar and lower limb kinematics and kinetics for evidence that lifting technique is associated with LBP

Purpose

To investigate if lumbar and lower limb kinematics or kinetics are different between groups with and without a history of LBP during lifting. Secondly, to investigate relationships between biomechanical variables and pain ramp during repeated lifting.

Methods

21 LBP and 20 noLBP participants completed a 100-lift task, where lumbar and lower limb kinematics and kinetics were measured during lifting, with a simultaneous report of LBP intensity every 10 lifts. Lifts were performed in a laboratory setting, limiting ecological validity.

Results

The LBP group used a different lifting technique to the noLBP group at the beginning of the task (slower and more squat-like). Kinetic differences at the beginning included less peak lumbar external anterior shear force and greater peak knee power demonstrated by the LBP group. However, at the end of the task, both groups lifted with a much more similar technique that could be classified as more stoop-like and faster. Peak knee power remained greater in the LBP group throughout and was the only kinetic difference between groups at the end of the lifting task. While both groups lifted using a more comparable technique at the end, the LBP group still demonstrated a tendency to perform a slower and more squat-like lift throughout the task. Only one of 21 variables (pelvic tilt at box lift-off), was associated with pain ramp in the LBP group. Conclusions: Workers with a history of LBP, lift with a style that is slower and more squat-like than workers without any history of LBP. Common assumptions that LBP is associated with lumbar kinematics or kinetics such as greater lumbar flexion or greater forces were not observed in this study, raising questions about the current paradigm around ‘safe lifting’.

Fear-avoidance beliefs are associated with reduced lumbar spine flexion during object lifting in pain-free adults

ABSTRACT

There is a long-held belief that physical activities such as lifting with a flexed spine is generally harmful for the back and can cause low back pain (LBP), potentially reinforcing fear-avoidance beliefs underlying pain-related fear. In patients with chronic LBP, pain-related fear has been shown to be associated with reduced lumbar range of motion during lifting, suggesting a protective response to pain. However, despite short-term beneficial effects for tissue health, recent evidence suggests that maintaining a protective trunk movement strategy may also pose a risk for (persistent) LBP due to possible pronociceptive consequences of altered spinal motion, potentially leading to increased loading on lumbar tissues. Yet, it is unknown if similar protective movement strategies already exist in pain-free individuals, which would yield potential insights into the role of fear-avoidance beliefs in motor behavior in the absence of pain. Therefore, the aim of this study is to test whether fear-avoidance beliefs influence spinal motion during lifting in a healthy cohort of pain-free adults without a history of chronic pain. The study subjects (N = 57) filled out several pain-related fear questionnaires and were asked to perform a lifting task (5kg-box). High-resolution spinal kinematics were assessed using an optical motion capturing system. Time-sensitive analyses were performed based on statistical parametric mapping. The results demonstrated time-specific and negative relationships between self-report measures of pain-related fear and lumbar spine flexion angles during lifting, indicating potential unfavorable interactions between psychological factors and spinal motion during lifting in pain-free subjects.

How accurate are visual assessments by physical therapists of lumbo-pelvic movements during the squat and deadlift?

OBJECTIVES

To investigate the accuracy of visual assessments made by physical therapists of lumbo-pelvic movements during the squat and deadlift and how much movement is considered injurious.

DESIGN

Quantitative Cross-sectional.

PARTICIPANTS

14 powerlifters, 10 Olympic weightlifters and six physical therapists.

SETTING

The lifters were recorded simultaneously by video and an inertial measurement unit (IMU) system while performing squats and deadlifts. The physical therapists assessed the videos and rated whether specific lumbo-pelvic movements were visible during the lifts and whether the movement amplitude was considered injurious.

MAIN OUTCOME MEASURES

The nominal visual assessments, if there was a movement and if it was considered injurious, were compared to the degrees of movement attained from the IMU system.

RESULTS

During the squat, a posterior pelvic tilt of ≥34° was required to visually detect the movement. For other lumbo-pelvic movements, there was no significant difference in the amount of movement between those who were assessed as moving or not moving their lumbo-pelvic area, nor was there a difference in movement amplitude between those who were assessed as having an increased risk of injury or not.

CONCLUSIONS

Physical therapists did not consistently detect lumbo-pelvic movements during squats and deadlifts when performed by competitive lifters.

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.

Changes in physiotherapy students' beliefs and attitudes about low back pain through pre-registration training

BACKGROUND

Implementation of best-practice care for patients with low back pain (LBP) is an important issue. Physiotherapists' who hold unhelpful beliefs are less likely to adhere to guidelines and may negatively influence their patients' beliefs. Pre-registration education is critical in moving towards a biopsychosocial model of care. This study aimed to investigate the changes in 2nd year physiotherapy students' beliefs about LBP after a module on spinal pain management and determine whether these changes were maintained at the end of academic training.

METHODS

During three consecutive calendar years, this longitudinal cohort study assessed physiotherapy students' beliefs with the Back Pain Attitudes Questionnaires (Back-PAQ) in their 1st year, before and after their 2nd year spinal management learning module, and at the end of academic training (3rd year). Unpaired t-tests were conducted to explore changes in Back-PAQ score.

RESULTS

The mean response rate after the spinal management module was 90% (128/143 students). The mean (± SD) Back-PAQ score was 87.73 (± 14.21) before and 60.79 (± 11.44) after the module, representing a mean difference of - 26.95 (95%CI - 30.09 to - 23.80, p < 0.001). Beliefs were further improved at the end of 3rd year (- 7.16, 95%CI - 10.50 to - 3.81, p < 0.001).

CONCLUSIONS

A spinal management learning module considerably improved physiotherapy students' beliefs about back pain. Specifically, unhelpful beliefs about the back being vulnerable and in need of protection were substantially decreased after the module. Improvements were maintained at the end of academic training one-year later. Future research should investigate whether modifying students' beliefs leads to improved clinical practice in their first years of practice.

Research Screener: a machine learning tool to semi-automate abstract screening for systematic reviews

BACKGROUND

Systematic reviews and meta-analyses provide the highest level of evidence to help inform policy and practice, yet their rigorous nature is associated with significant time and economic demands. The screening of titles and abstracts is the most time consuming part of the review process with analysts required review thousands of articles manually, taking on average 33 days. New technologies aimed at streamlining the screening process have provided initial promising findings, yet there are limitations with current approaches and barriers to the widespread use of these tools. In this paper, we introduce and report initial evidence on the utility of Research Screener, a semi-automated machine learning tool to facilitate abstract screening.

METHODS

Three sets of analyses (simulation, interactive and sensitivity) were conducted to provide evidence of the utility of the tool through both simulated and real-world examples.

RESULTS

Research Screener delivered a workload saving of between 60 and 96% across nine systematic reviews and two scoping reviews. Findings from the real-world interactive analysis demonstrated a time saving of 12.53 days compared to the manual screening, which equates to a financial saving of USD 2444. Conservatively, our results suggest that analysts who scan 50% of the total pool of articles identified via a systematic search are highly likely to have identified 100% of eligible papers.

CONCLUSIONS

In light of these findings, Research Screener is able to reduce the burden for researchers wishing to conduct a comprehensive systematic review without reducing the scientific rigour for which they strive to achieve.

Pathways to job engagement: evidences from the software industry

Purpose

The purpose of this paper is to broaden the link between workplace flexibility (WF) and job engagement (JE) while considering quality of work life (QWL) as mediator and the use of knowledge sharing (KS) as moderator. While numerous studies have focused solely on the importance of WF, QWL, KS and JE only exclusively, this study integrates them to delineate their association and to empirically assess the relationships. To advance an in-depth knowledge of these aspects, the study goes beyond the conventional findings.

Design/methodology/approach

In total, 378 employees from software firms in India participated in the questionnaire-based survey. It is a cross-sectional study. The proposed conceptual model and hypothesis were analyzed and tested by structural equation modeling and process macro. Drawing on the person environment (P-E) fit theory and social exchange theory, the authors discuss how QWL mediates and KS moderates the association between WF and JE.

Findings

Results indicate a positive association between WF and JE. Furthermore, it was found that QWL mediated and KS moderated this association.

Practical implications

Findings of the study will help the management to comprehend the significance QWL interventions in increasing their JE. This paper may encourage HR managers in the Information Technology (IT) industry to perceive the importance of KS. Moreover, the study accentuates flexible work options as essential phenomenon to positively impinge on the JE of employees in the IT sector.

Originality/value

The present study tries to enrich the extant research on WF and JE while it demonstrates the use of QWL interventions and KS as vital constructs that may significantly and positively influence JE.

Adios, 2020: The Year of Living Distantly

Editor-in-Chief Clare Ardern thanks all of those who contributed to JOSPT in 2020. J Orthop Sports Phys Ther 2020;50(12):653-656. doi:10.2519/jospt.2020.0110.

Effectiveness of a lumbopelvic monitor and feedback device to change postural behaviour: the ELF cluster randomised controlled trial

OBJECTIVES

The aim of this clustered, randomised controlled trial was to assess the effectiveness of a lumbopelvic postural feedback device for changing postural behaviour in a group of healthcare workers. We hypothesised that workers exposed to auditory postural feedback would reduce the number of times forward bending posture is adopted at work.

METHODS

This was a participant and assessor blinded, randomised, sham-controlled trial with blocked cluster random allocation. We recruited healthcare workers from aged care institutions. Healthcare sites were randomly allocated to the feedback or sham group (SG). A postural monitoring and feedback device was used to monitor and record lumbopelvic forward bending posture, and provided audio feedback whenever the user sustained lumbopelvic forward bending posture that exceeded predefined thresholds. The primary outcome measure was postural behaviour (exceeding thresholds). We used a robust variant of repeated measures mixed-effect model for assessing within-group and between-group differences in postural behaviour.

RESULTS

We recruited 19 sites, and 130 healthcare workers participated. There were no within-group changes on the number of times postural threshold was exceeded at 1-week follow-up (feedback group: -0.7, 95% CI -2.61 to 0.72; SG -0.3, -1.65 to 0.98), and no differences (0.05, 95% CI -1.83 to 1.94) between SG and feedback group.

CONCLUSIONS

Findings from this trial indicate that audio feedback provided by a postural monitor device did not reduce the number of times healthcare workers exceeded the postural threshold.

TRIAL REGISTRATION NUMBER

ACTRN12616000449437.

Electronic Skin Wearable Sensors for Detecting Lumbar-Pelvic Movements

Background: A nanomaterial-based electronic-skin (E-Skin) wearable sensor has been successfully used for detecting and measuring body movements such as finger movement and foot pressure. The ultrathin and highly sensitive characteristics of E-Skin sensor make it a suitable alternative for continuously out-of-hospital lumbar–pelvic movement (LPM) monitoring. Monitoring these movements can help medical experts better understand individuals’ low back pain experience. However, there is a lack of prior studies in this research area. Therefore, this paper explores the potential of E-Skin sensors to detect and measure the anatomical angles of lumbar–pelvic movements by building a linear relationship model to compare its performance to clinically validated inertial measurement unit (IMU)-based sensing system (ViMove). Methods: The paper first presents a review and classification of existing wireless sensing technologies for monitoring of body movements, and then it describes a series of experiments performed with E-Skin sensors for detecting five standard LPMs including flexion, extension, pelvic tilt, lateral flexion, and rotation, and measure their anatomical angles. The outputs of both E-Skin and ViMove sensors were recorded during each experiment and further analysed to build the comparative models to evaluate the performance of detecting and measuring LPMs. Results: E-Skin sensor outputs showed a persistently repeating pattern for each movement. Due to the ability to sense minor skin deformation by E-skin sensor, its reaction time in detecting lumbar–pelvic movement is quicker than ViMove by ~1 s. Conclusions: E-Skin sensors offer new capabilities for detecting and measuring lumbar–pelvic movements. They have lower cost compared to commercially available IMU-based systems and their non-invasive highly stretchable characteristic makes them more comfortable for long-term use. These features make them a suitable sensing technology for developing continuous, out-of-hospital real-time monitoring and management systems for individuals with low back pain.