Measures of pain and physical function in patients with low back pain

Muscle activity and rehabilitation in spinal stenosis (MARSS) after conservative therapy and surgical decompression with or without fusion: Protocol for a partially randomized patient preference trial on rehabilitation timing

Background

Patients affected by lumbar spinal stenosis (LSS) suffer from a multifactorial degeneration of the lumbar spine resulting in narrowing of the neuroforamina and spinal canal, leading to various functional limitations. It remains unclear whether LSS patients after surgery would benefit from early post-operative rehabilitation, or if a delayed rehabilitation would be more advantageous. The purpose of this partially randomized patient preference trial is to evaluate the impact of post-operative rehabilitation timing as well as surgical intervention type on psychometric properties and functional outcomes in patients with LSS.

Methods

Data for this patient preference trial are collected before and after surgical (decompression only or decompression and fusion) and rehabilitative interventions as well as six, 12 and 24 months after completing rehabilitation. The study participants are patients diagnosed with LSS who are at least 18 years old. After a medical check-up, participants will complete patient-reported outcome measures (PAREMO-20, SIBAR, FREM-8, SF-12, SFI, ODI) and different functional assessments (functional reach test, loaded reach test, handgrip strength, standing balance control, 6-min walk test).

Ethics and dissemination

The results of this study will be published through peer-reviewed publications and scientific contributions at national and international conferences. This research has been approved by the Institutional Review Board of Martin Luther University Halle-Wittenberg (reference number: 2022-128).

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.

Pain Mechanisms in Low Back Pain: A Systematic Review With Meta-analysis of Mechanical Quantitative Sensory Testing Outcomes in People With Nonspecific Low Back Pain

BACKGROUND

Mechanical quantitative sensory testing (QST) assesses sensory functioning and detects functional changes in (central) nociceptive processing. It has been hypothesized that these functional changes might be apparent in people with nonspecific low back pain (LBP), although the results are mixed.

OBJECTIVE

The aim of this systematic review was to examine whether sensory function, measured with QST, was altered in people with nonspecific LBP.

METHODS

This systematic review was conducted according to PRISMA guidelines. Six databases were searched for relevant literature. Studies comparing mechanical QST measures involving people with subacute and chronic LBP and healthy controls were included if (1) pressure pain thresholds (PPTs), (2) temporal summation, or (3) conditioned pain modulation were reported. Risk of bias was assessed using the Newcastle-Ottawa scale. When possible, the results from different studies were pooled.

RESULTS

Twenty-four studies were included. Scores on the Newcastle-Ottawa scale varied between 1 and 6 points. People with nonspecific LBP, compared to healthy controls, had significantly lower PPTs at remote sites and increased temporal summation at the lower back. The PPTs measured at the scapula were significantly lower in patients with nonspecific LBP than in healthy controls (pooled mean difference, 119.2 kPa; 95% confidence interval: 91.8, 146.6 kPa; P<.001).

CONCLUSION

The PPT measurements at remote body parts were significantly lower in people with nonspecific LBP compared with healthy controls. Temporal summation and conditioned pain modulation measurements had mixed outcomes.

LEVEL OF EVIDENCE

Therapy, level 3a. J Orthop Sports Phys Ther 2019;49(10):698-715. Epub 23 Aug 2019. doi:10.2519/jospt.2019.8876.

Reducing sedentary behaviour to decrease chronic low back pain: the stand back randomised trial

OBJECTIVE

The Stand Back study evaluated the feasibility and effects of a multicomponent intervention targeting reduced prolonged sitting and pain self-management in desk workers with chronic low back pain (LBP).

METHODS

This randomised controlled trial recruited 27 individuals with chronic LBP, Oswestry Disability Index (ODI) >10% and desk jobs (sitting ≥20 hours/week). Participants were randomised within strata of ODI (>10%-<20%, ≥20%) to receive bimonthly behavioural counselling (in-person and telephone), a sit-stand desk attachment, a wrist-worn activity-prompting device and cognitive behavioural therapy for LBP self-management or control. Self-reported work sitting time, visual analogue scales (VAS) for LBP and the ODI were assessed by monthly, online questionnaires and compared across intervention groups using linear mixed models.

RESULTS

Baseline mean (SD) age was 52 (11) years, 78% were women, and ODI was 24.1 (10.5)%. Across the 6-month follow-up in models adjusted for baseline value, work sitting time was 1.5 hour/day (P<0.001) lower comparing intervention to controls. Also across follow-up, ODI was on average 8 points lower in intervention versus control (P=0.001). At 6 months, the relative decrease in ODI from baseline was 50% in intervention and 14% in control (P=0.042). LBP from VAS was not significantly reduced in intervention versus control, though small-to-moderate effect sizes favouring the intervention were observed (Cohen's d ranged from 0.22 to 0.42).

CONCLUSION

An intervention coupling behavioural counselling targeting reduced sedentary behaviour and pain self-management is a translatable treatment strategy that shows promise for treating chronic LBP in desk-bound employees.

TRIAL REGISTRATION NUMBER

NCT0224687; Pre-results.

Comparison of standing postural control and gait parameters in people with and without chronic low back pain: a cross-sectional case-control study

Objective

Differences in postural control and gait have been identified between people with and without chronic low back pain (CLBP); however, many previous studies present data from small samples, or have used methodologies with questionable reliability. This study, employing robust methodology, hypothesised that there would be a difference in postural control, and spatiotemporal parameters of gait in people with CLBP compared with asymptomatic individuals.

Methods

This cross-sectional case–control study age-matched and gender-matched 16 CLBP and 16 asymptomatic participants. Participants were assessed barefoot (1) standing, over three 40 s trials, under four posture challenging conditions (2) during gait. Primary outcome was postural stability (assessed by root mean squared error of centre of pressure (CoP) displacement (CoP_RMSEAP) and mean CoP velocity (CoP_VELAP), both in the anteroposterior direction); gait outcomes were hip range of movement and peak moments, walking speed, cadence and stride length, assessed using force plates and a motion analysis system.

Results

There were no differences between groups in CoP_RMSEAP (P=0.26), or CoP_VELAP (P=0.60) for any standing condition. During gait, no differences were observed between groups for spatiotemporal parameters, maximum, minimum and total ranges of hip movement, or peak hip flexor or extensor moments in the sagittal plane.

Conclusions

In contrast to previous research, this study suggests that people with mild to moderate CLBP present with similar standing postural control, and parameters of gait to asymptomatic individuals. Treatments directed at influencing postural stability (eg, standing on a wobble board) or specific parameters of gait may be an unnecessary addition to a treatment programme.

The Impact of a Cognitive Behavioral Pain Management Program on Sleep in Patients with Chronic Pain: Results of a Pilot Study

OBJECTIVE

To determine the impact of a cognitive behavioral pain management program on sleep in patients with chronic pain.

DESIGN

Prospective nonrandomized controlled pilot study with evaluations at baseline and 12 weeks.

SETTING

Out-patient multidisciplinary cognitive behavioral pain management program in a university teaching hospital.

SUBJECTS

Patients with chronic pain who fulfilled the criteria for participation in a cognitive behavioral pain management program.

METHODS

Patients assigned to the intervention group (n = 24) completed a 4 week cognitive behavioral pain management program, and were compared with a waiting list control group (n = 22). Assessments for both groups occurred at baseline and two months post cognitive behavioral pain management program. Outcome measures included self-report (Pittsburgh Sleep Quality Index) and objective (actigraphy) sleep measures, pain and quality of life measures.

RESULTS

Both groups were comparable at baseline, and all had sleep disturbance. The Pittsburgh Sleep Quality Index correlated with only two of the seven objective sleep measures (fragmentation index r = 0.34, P = 0.02, and sleep efficiency percentage r = -0.31, P = 0.04). There was a large treatment effect for cognitive behavioral pain management program group in mean number of wake bouts (d = 0.76), where a significant group*time interaction was also found (P = 0.016), showing that the CBT-PMP group improved significantly more than controls in this sleep variable.

CONCLUSIONS

Patients attending a cognitive behavioral pain management program have high prevalence of sleep disturbance, and actigraphy technology was well tolerated by the patients. Preliminary analysis of the impact of a cognitive behavioral pain management program on sleep is promising, and warrants further investigation.

A novel biomechanical device improves gait pattern in patient with chronic nonspecific low back pain

STUDY DESIGN

A retrospective study on patients with chronic nonspecific low back pain (NSLBP).

OBJECTIVE

To describe the gait stride characteristics of patients with chronic NSLBP, and to examine the effect of a novel biomechanical device on the gait stride characteristics of these patients.

SUMMARY OF BACKGROUND DATA

Patient with NSLBP alters their gait patterns. This is considered a protective mechanism as patients try to avoid extensive hip and spine ranges of motion and minimize forces and moments acting on the body. In addition, there are changes in the neuromuscular control system in patients with LBP that could possibly be attributed to the effects of pain on motor control.

METHODS

Nineteen patients underwent a gait test, using an electronic walkway, at baseline and after 12 weeks of treatment. Spatiotemporal parameters were used to identify changes in gait pattern. A novel biomechanical device comprised of 4 modular elements attached to foot-worn platforms was used in the study. The modules are 2 convex shaped biomechanical elements attached to each foot, one is located under the hindfoot region and the other is located under the forefoot region. The device was individually calibrated to each patient. The patients were instructed to walk with the calibrated biomechanical device on a daily basis for a period of 12 weeks.

RESULTS

Significant differences were found at baseline and after 12 weeks in normalized velocity (P = 0.03), cadence (P < 0.01), left normalized step length (P = 0.02), right normalized step length (P = 0.02), right swing (P < 0.01), right stance (P < 0.01), left single limb support (P = 0.01), left double limb support (P = 0.02), and right double limb support (P = 0.02).

CONCLUSION

Patients with NSLBP treated with the novel biomechanical device for 3 months increased walking speed through longer step length and eliminated asymmetrical differences.

Influence of pain distribution on gait characteristics in patients with low back pain: part 1: vertical ground reaction force

STUDY DESIGN

In a cross-sectional study, vertical ground reaction force (GRF) during 2 speeds of walking were compared between 3 age- and sex-matched groups: back pain only (BPO) group, back pain with referred leg pain (LGP) group, and a control group.

OBJECTIVE

The purpose was to evaluate the influence of pain distribution on vertical GRF of patients with low back problems during 2 walking speed conditions: preferred and fastest speeds.

SUMMARY OF BACKGROUND DATA

People with low back pain often have difficulty walking. A better understanding of how pain distribution differentially affects walking will facilitate clinicians' assessment and enhance treatment in patients with low back pain problems.

METHODS

All participants walked on a 7.62-m walkway. Vertical GRF parameters were recorded during stance phase using a force platform for each walking speed condition. Multivariate analysis of covariance was used for statistical analysis, with gait velocity as the covariate.

RESULTS

The BPO and control groups did not differ significantly in vertical GRF during both walking speed conditions (P > or = 0.11). All vertical GRF parameters of the LGP group, except the peak loading force (P = 0.374), were significantly less than those of the control group during preferred walking speed condition (P < or = 0.008). However, there was no significant difference in the vertical GRF components between LGP and control groups during the fastest walking speed condition (P > or = 0.07).

CONCLUSIONS

Pain distribution of people with low back problems differentially influences the vertical GRF they experience during walking. When walking at preferred speed, those with referred leg pain seem to use additional strategies besides walking slowly to attenuate the amount of force imposed on their painful leg. When challenged to walk at their fastest speed, people with back pain only walk as fast and withstand comparable amount of force as their pain-free counterparts.

Biomechanical assessments of lumbar spinal function. how low back pain sufferers differ from normals. implications for outcome measures research. part i: kinematic assessments of lumbar function

OBJECTIVE

To review new and advanced biomechanical assessment techniques for the lumbar spine and illustrate the differences in lumbar function in patients with low back pain and asymtomatic subjects.

DATA SOURCES

The biomedical literature was searched for research and reviews on spinal kinematic differences between low back pain subjects and healthy controls. A data search for articles indexed on MEDLINE until April 2002 was performed.

RESULTS

Kinematic measurements of lumbar function were categorized into 3 areas where low back patients may differ from normals: (1) end range of motion during simple movements; (2) higher order kinematics (displacement, velocity, and acceleration) during complex movement tasks; and (3) spinal proprioception. The assessment of higher order kinematics during complex movement tasks is the most highly researched and the most successful in describing differences between the populations. The use of simple end range of motion appears questionable, while assessing spinal proprioception is the least researched, yet shows potential in highlighting differences between low back sufferers and asymptomatics.

CONCLUSION

Current kinematic biomechanical assessment techniques are capable of identifying functional differences between low back pain populations and controls. The use and validity of the majority of these techniques as outcome measures are currently unknown, yet may be valuable in generating functional diagnoses, evaluating the mechanisms of current therapies, and prescribing specific rehabilitation programs.

Back pain, physical function, and estimates of aerobic capacity: what are the relationships among methods and measures?

OBJECTIVES

To establish the correlations of measures of self-reported disability, self-efficacy, physical performance, level of pain, and estimates of aerobic capacity (PvO2 ) in subjects with low back pain.

DESIGN

Fifty-one low back pain subjects, ranging in age from 26 to 65 yr, entered the study. Participants completed the Roland-Morris Disability Questionnaire and the self-efficacy questionnaire. Physical performance was evaluated by the loaded-reach test, sit/stand test, 5-min walk test, 50-foot walking test, and time to roll from right to left. Pain intensity and pain affect were measured using two visual analog scales. PvO2 was predicted from an equation.

RESULTS

The correlation coefficient among the physical performance outcomes ranged from 0.47 to 0.78. Pain measures had low correlations with measures of function but stronger correlations with other self-report measures. The disability measure correlated moderately with physical performance. Correlations between PvO2 and all other measurements were minimal, except for the 5-min walk test.

CONCLUSION

Performance and disability were more consistent in evaluating low back pain. PvO2 failed to correlate with most other aspects of low back pain. This study suggests that aerobic capacity might not be a primary concern for patients with low back pain.

Pelvis-thorax coordination in the transverse plane during walking in persons with nonspecific low back pain

STUDY DESIGN

Transverse pelvis and thorax rotations were studied during walking in 39 patients with nonspecific low back pain and 19 healthy participants.

OBJECTIVES

To gain insight into the consequences of low back pain for gait and to identify clinically useful measures for characterizing the quality of walking in patients with low back pain.

SUMMARY OF BACKGROUND DATA

Gait studies in patients with low back pain have reported a decrease in walking velocity. In normal gait, in-phase pelvis-thorax coordination (synchronicity) evolves toward antiphase coordination (counterrotation) as walking velocity increases. This study examined the effect of walking velocity on pelvis and thorax rotations in patients with low back pain.

METHODS

Amplitudes of pelvis and thorax rotations were calculated, and spectral analyses were performed. Pelvis-thorax coordination was characterized in terms of relative Fourier phase, and coupling strength was assessed by means of cross-spectral analysis.

RESULTS

In comparison with healthy participants, relative Fourier phase was significantly smaller in low back pain patients for walking velocities of 3.8 km/h and higher, whereas coupling strength was significantly higher for velocities from 1.4 to 3.0 km/h. No significant group differences were found in amplitude or spectral content of individual pelvis and thorax rotations.

CONCLUSION

In comparison with healthy participants, the gait of patients with low back pain was characterized by a more rigid, less flexible pelvis-thorax coordination in the absence of significant differences in the kinematics of the component rotations. This result suggests that coordination measures are more adequate in assessing quality of walking in patients with low back pain than are kinematic measures pertaining to the individual segment rotations, and that conservative therapy should use methods aimed at improving intersegmental coordination.

Physical performance: differences in men and women with and without low back pain

OBJECTIVE

To determine the extent to which there may be major differences in scores on a battery of physical performance tasks among men with nonspecific, mechanical low back pain (LBP), women with LBP, healthy men, and healthy women.

DESIGN

Case series survey.

SETTING

A referral-based orthopedic clinic.

PATIENTS

Thirty-three men and 46 women with LBP. Control Subjects: Twenty-one men and 25 women healthy controls.

INTERVENTION

Completion of six clinician-assessed physical performance tasks and self-report inventories.

MAIN OUTCOME MEASURE

Performance scores on distance walked in 5 minutes, 50-foot walk at fastest speed, repeated sit-to-stand, repeated trunk flexion, loaded forward reach, and the Sorensen fatigue tasks.

RESULTS

Discriminant function analysis revealed that the four groups of subjects performed the physical tasks significantly different in two major ways: (1) healthy control subjects outperformed LBP patients, irrespective of gender, on tasks involving trunk control, coordination, and stability while withstanding heavy or quickly changing loads on the spine; (2) men outperformed women, irrespective of patient or nonpatient status, on tasks involving anthropometric features of limb length. The findings provide guidance on reasonable performance expectations for men and women patients with LBP. Future studies of treatment effectiveness also will be able to assess physical performance change in terms of the intersection between standards set by the men and women healthy control subjects and those of men and women patients. However, whether a return to nonpatient status is an appropriate treatment goal is left to future research.

Psychometric characteristics and clinical usefulness of physical performance tests in patients with low back pain

STUDY DESIGN

The psychometric properties and clinical use of a battery of physical performance measures were tested on 44 patients with low back pain and 48 healthy, pain-free control subjects.

OBJECTIVES

Reliability, validity, and clinical use of nine physical performance measures were evaluated.

SUMMARY OF BACKGROUND DATA

Although physical performance measures have potential use in evaluation, treatment planning, and determination of treatment outcome, there is sparse systematic investigation of their reliability, validity, and clinical use.

METHODS

Forty-four subjects with low back pain and 48 healthy pain-free subjects participated. The following physical performance measures were tested: distance walked in 5 minutes; 50-foot walk at fastest speed; 50-foot walk at preferred speed; 5 repetitions of a sit-to-stand task; 10 repetitions of a repeated trunk flexion task; timed up-and-go task; unloaded forward reach task; loaded forward reach task; and Sorensen fatigue test. Subjects were assessed twice on 2 days.

RESULTS

All measures had excellent intertester reliability (intraclass correlation coefficient [ICC]1,1 > 0.95). Test-retest (within session) reliability was adequate for all measures (ICC1,1 > 0.83) except repeated trunk flexion (ICC1,1 > 0.45) in the low back pain group. Test-retest (day-to-day) reliability ranged between 0.59 and 0.88 in the low back pain group and between 0.46 and 0.76 in the control group. Day-to-day reliability improved when the averages of two trials of repeated trunk flexion and sit-to-stand were used (0.76-0.91 low back pain group and 0.62-0.89 control group). Results of a multivariate analysis of variance showed a significant effect of group (F10,65 = 3.52, P = 0.001). Results of univariate analyses showed significant group differences on all measures except the 50-foot walk at preferred speed and unloaded forward reach. Self-report of disability was moderately correlated with the performance tasks (r = 0.400 to -0.603).

CONCLUSIONS

The results provide support for the use of these physical performance measures as a complement to patient self-report.