The effect of load on the coordination of the trunk for subjects with and without chronic low back pain during flexion-extension and lateral bending tasks

Trunk control during standing reach: A dynamical system analysis of movement strategies in patients with mechanical low back pain

The purpose of this study was to quantify lumbo-pelvic control differences between patients with mechanical low back pain (MLBP) and asymptomatic controls using a dynamical systems approach to data reduction and interpretation. Subjects were 30 patients with chronic MLBP (age: 41.1+/-8.9 years, body mass index: 26.2+/-5.2 kg/m(2)) and 35 asymptomatic controls (age: 38.8+/-9.2 years, body mass index: 25.3+/-4.8 kg/m(2)). Kinematic data were collected from the femur, pelvis and lumbar spine during repeated trials of bilateral forward reaching under two loading conditions. Sagittal plane angular motion was filtered and time normalized. Continuous relative phases were then calculated for each data point. Mean absolute relative phase (MARP) and deviation phase (DP) parameters were derived to quantify intersegmental coordination and pattern variability. Mixed-model ANOVAs revealed that lumbo-pelvic coordination was more separated in time and more variable in the chronic MLBP group during this task. Trunk neuromuscular control was thus altered in our MLBP group. Unresolved extensor muscle dysfunction is suggested by (a) preliminary analysis of phase plane trajectories, (b) subjects' greater difficulty controlling aspects of the task that required the extensors to contribute to trunk stability and primary movement control.

Digital Human Modeling for Workspace Design

Digital human modeling (DHM) technology offers human factors/ergonomics specialists the promise of an efficient means to simulate a large variety of ergonomics issues early in the design of products and manufacturing workstations. It rests on the premise that most products and manufacturing work settings are specified and designed by using sophisticated computer-aided design (CAD) systems. By integrating a computer-rendered avatar (or hominoid) and the CAD-rendered graphics of a prospective workspace, one can simulate issues regarding who can fit, reach, see, manipulate, and so on. In this chapter, I briefly describe the development of various DHM methods to improve CAD systems. Past concerns about early DHM methods are discussed, followed by a description of some of the recent major developments that represent attempts by various groups to address the early concerns. In this latter context, methods are described for using anthropometric databases to ensure that population shape and size are well modeled. Efforts to integrate various biomechanical models into DHM systems also are described, followed by a section that outlines how human motions are being modeled in different DHM systems. In a final section, I discuss recent work to merge cognitive models of human performance with DHM models of manual tasks. Much has been accomplished in recent years to make digital human models more useful and effective in resolving ergonomics issues during the design of products and manufacturing processes, but much remains to be learned and applied in this rapidly evolving aspect of ergonomics.

Lumbar position sense with extreme lumbar angle

Tasks involving flexed torso postures have a high incidence of low back injuries. Changes in the ability to sense and adequately control low back motion may play a role in these injuries. Previous studies examining position sense errors of the lumbar spine with torso flexion found significant increases in error with flexion. However, there has been little research on the effect of lumbar angle. In this study, the aim of the study was to examine how position sense errors would change with torso flexion as a function of the target lumbar angle. Fifteen healthy volunteers were asked to assume three different lumbar angles (maximum, minimum and mid-range) at three different torso flexion angles. A reposition sense protocol was used to determine a subject's ability to reproduce the target lumbar angles. Reposition sense error was found to increase 69% with increased torso flexion for mid-range target curvatures. With increasing torso flexion, the increase in reposition sense errors suggests a reduction in sensation and control in the lumbar spine that may increase risk of injury. However, the reposition error was smaller at high torso flexion angles in the extreme target curvatures. Higher sensory feedback at extreme lumbar angles would be important in preventing over-extension or over-flexion. These results suggest that proprioceptive elements in structures engaged at limits (such as the ligaments and facet joints), may provide a role in sensing position at extreme lumbar angles. Sensory elements in the muscles crossing the joint may also provide increased feedback at the edges of the range of motion.

Chronic non-specific low back pain - sub-groups or a single mechanism?

BACKGROUND

Low back pain is a substantial health problem and has subsequently attracted a considerable amount of research. Clinical trials evaluating the efficacy of a variety of interventions for chronic non-specific low back pain indicate limited effectiveness for most commonly applied interventions and approaches.

DISCUSSION

Many clinicians challenge the results of clinical trials as they feel that this lack of effectiveness is at odds with their clinical experience of managing patients with back pain. A common explanation for this discrepancy is the perceived heterogeneity of patients with chronic non-specific low back pain. It is felt that the effects of treatment may be diluted by the application of a single intervention to a complex, heterogeneous group with diverse treatment needs. This argument presupposes that current treatment is effective when applied to the correct patient. An alternative perspective is that the clinical trials are correct and current treatments have limited efficacy. Preoccupation with sub-grouping may stifle engagement with this view and it is important that the sub-grouping paradigm is closely examined. This paper argues that there are numerous problems with the sub-grouping approach and that it may not be an important reason for the disappointing results of clinical trials. We propose instead that current treatment may be ineffective because it has been misdirected. Recent evidence that demonstrates changes within the brain in chronic low back pain sufferers raises the possibility that persistent back pain may be a problem of cortical reorganisation and degeneration. This perspective offers interesting insights into the chronic low back pain experience and suggests alternative models of intervention.

SUMMARY

The disappointing results of clinical research are commonly explained by the failure of researchers to adequately attend to sub-grouping of the chronic non-specific low back pain population. Alternatively, current approaches may be ineffective and clinicians and researchers may need to radically rethink the nature of the problem and how it should best be managed.

The relationship between pain-related fear and lumbar flexion during natural recovery from low back pain

Pain-related fear has been associated with avoidance behavior and increased risk for chronic low back pain; however, few studies have examined how pain-related fear relates specifically to motion of the spine following an acute episode of back pain. Thirty-six participants with a recent episode of low back pain were recruited from the general population using a combination of fliers and radio advertisements. To explore the natural recovery from low back pain we recruited individuals who were not seeking medical care. Participants performed a forward bending task at 3, 6, and 12 weeks following onset of low back pain. Three-dimensional joint motions of the spine and hip were recorded using an electromagnetic tracking device. Initial assessments of low back pain and pain-related fear were then correlated with joint excursions observed during each forward bending. Lumbar motion was inversely related to pain-related fear, but not low back pain, at all three testing sessions. In contrast, hip motion was inversely related to pain at all three testing sessions but was not related to fear. These findings suggest that pain-related fear results in avoidance behavior that specifically limits or restricts motion of the lumbar spine.

Coordination and timing of spine and hip joints during full body reaching tasks

Coupling of spine and hip joints during full body reaching tasks was investigated in 16 participants (8 male and 8 female) who performed reaching tasks at comfortable and fast-paced movement speeds to three targets located in a para-sagittal plane. The participants paused at target contact for 500ms and then returned to an upright posture. Three-dimensional joint motions of the spine and hip were recorded using an electromagnetic tracking device. We found an effect of movement phase (i.e., reach and return) on the onset timing of the spine and hip joints. For most target locations and movement speeds, spine motion onset preceded hip motion onset during the reaching phase of the movement task. In the reach phase, when averaged across all movement conditions, spine joint motion preceded hip joint motion by an average of 48.9ms. In contrast, in the return phase, hip joint motion preceded spine joint motion by an average of 63.0ms. Additionally, when participants were instructed to use either a knee flexion or knee extension strategy to perform the reaching tasks there was no effect of movement strategy on timing of the spine and hip. There was also no effect of target height on the spine-hip ratio, but as movement speed increased, the spine/hip ratio decreased for all target locations due primarily to an increase in hip joint excursion. The findings indicate clear differences in onset timing of the spine and hip joints during reaching tasks that necessitate some forward bending of the trunk and that onset timing is reversed for the return to an upright posture.

Principal component analysis of lifting waveforms

BACKGROUND

One limiting factor in lifting research design has been the inability to effectively analyze waveform data, especially when differences in body mass, height, and load magnitude influence the derived kinetic variables. The purpose of this study was to demonstrate the sensitivity of principal component analysis to quantify clinically relevant differences in kinetic lifting waveforms over three load magnitudes and between two separate populations.

METHODS

Principal component analysis was applied to five kinetic lifting waveforms. The derived principal component scores were used as the dependent measures in a two-way (clinical status x load magnitude) MANOVA.

FINDINGS

Significant low back pain group differences (P<0.05) were found for three of the principal component scores on extension moment generation in the sacral and thoracic regions and for trunk compression. Significant differences were found for each variable with respect to the magnitude across the entire lift time between the three load conditions, as well as four significant differences related to inferred mechanical changes that resulted from lifting increasingly heavier loads.

INTERPRETATION

Principal component analysis of kinetic lifting waveforms was shown to be insensitive to a confounding factor of different load magnitudes when attempting to identify previously determined clinically relevant differences in the waveform trajectories. The analysis was able to partition the variability attributed to the direct influence of different external load magnitudes, versus those differences in spinal loading that arose from the variations in the lifting mechanics of increasing loads. The technique could be beneficial for other kinetic analyses where confounding magnitude modifiers like body size are present.

Posture and motion variability in non-repetitive manual materials handling tasks

In developing a motion prediction model it is important to initially consider the sources of variability that a model should reproduce. This initial step is followed by model evaluation, where the variability predicted by the model can be a useful test parameter. An existing lifting-motion dataset collected under controlled laboratory conditions was employed here to evaluate quantitatively some important sources of variability for lift motion modeling. The main source of variability was the segment being analyzed, which accounted for more than 20% of the overall variability. There was substantial left-right symmetry in individual segment variability estimates, which were largest for the upper arm segment and tended to be larger for the upper limbs than the lower limbs. Task-related factors accounted for variability mainly as a function of the segment being considered. Within-participant variability contributions to the dataset were relatively small, whereas the contribution of between-participants variability was dependent on the segment (as large as 50%) and could indicate different lifting strategies across participants. Variability was found to remain relatively constant across the different stages of the lifting movements. Implications of these results for the development and evaluation of motion prediction models are presented. Specifically, while task characteristics may be important modifiers of the mean segment trajectory during a lifting movement, their influence on variability differs based on the segment that is being considered. The relevance of the findings is discussed in terms of their utility in the ergonomic design of tasks and work spaces.

Body motion during repetitive isodynamic lifting: a comparative study of normal subjects and low-back pain patients

To quantify performance differences between patients with low-back pain (LBP) and a control group during their performance of a repetitive isodynamic lifting task. Case-control study was done. LBP patients were recruited and tested at an outpatient ambulatory chronic pain rehabilitation program before treatment was begun. Fifty-three LBP patients who had prolonged back pain and 53 age and gender matched pain-free control subjects. Overall lifting performance measures included weight lifting and number of lifts completed; kinematic measures of hip and knee movements during lifting were described by hyperbolic tangent models, and included static measures of starting and ending angles, and dynamic measures of midpoint, falltime, and lift speed. Control subjects completed significantly more lifts and lifted more weight than patients. Starting hip flexion was greater for controls and starting knee flexion was greater for patients, indicating that patients used more of a leg lift. Patients and controls also differed significantly on dynamic measures, particularly lifting speed and hip and knee temporal midpoints. Major static and dynamic motion differences were found between LBP patients and controls as they performed repetitive lifting under a constant load. These findings indicate that body motion parameters, in addition to more common strength and endurance measures, are necessary to describe the impact of persistent LBP on a person's lifting abilities.

Effect of pregnancy on trunk range of motion when sitting and standing

BACKGROUND

During pregnancy, apposition of body segments and changes in trunk mobility and motion control due to increased mass and dimensions may reduce the functional range of motion of the trunk segments. Although static postures have been investigated, dynamic trunk motion during pregnancy in sitting and standing has had very limited investigation.

METHODS

Included in the study was a volunteer sample of convenience of nine primiparous and multiparous women. Twelve nulliparous females formed a control group. The subjects were filmed while performing maximum seated and standing trunk forward flexion, side-to-side flexion and seated axial rotation. A repeated measures anova was used to investigate systematic changes in the motion of the pelvic and thoracic segments and the thoracolumbar spines during pregnancy.

RESULTS

As pregnancy progressed, there was no significant decrease in the range of side-to-side flexion. For forward flexion and axial rotation, motion of the thoracic segment and the thoracolumbar spine was significantly reduced. Movement of the pelvis was less affected. Base of support width was increased for forward flexion and side-to-side flexion.

CONCLUSIONS

In late pregnancy, strategies such as increasing the width of the base of support and reducing obstruction from other body parts were used to minimize the effects of increased trunk mass and girths. Not all trunk segment motion was affected equally. The differing effect on individual trunk segment motion may lead to altered movement patterns during functional tasks.

Joint coordination during whole-body lifting in women with low back pain after pregnancy

OBJECTIVE

To quantify differences in the kinematics of lifting between women with low back and/or pelvic pain after pregnancy and women without.

DESIGN

Comparison study.

SETTING

Research laboratory.

PARTICIPANTS

Volunteer sample of 7 women with pain (positive pain drawing, no physical examination) and 9 female controls (not matched).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Duration of downward and upward phases, relative instant of box lift-off, joint angles, spatial angles of trunk and pelvis, pelvic angle relative to trunk, and phase angle relationships between joints.

RESULTS

The duration of the upward phase +/- standard deviation was longer in the pain group (1731+/-290 ms vs 1489+/-187 ms, P=.031). At box lift-off, this group had less hip joint flexion (101.9 degrees +/-20.8 degrees vs 78.7 degrees +/-12.4 degrees, P=.015) but more backward pelvis tilt relative to the trunk, that is, more lumbar spine flexion (126.3 degrees +/-16.8 degrees vs 109.0 degrees +/-12.3 degrees, P=.031). The pain group showed an immediate transition from lumbar spine flexion to extension, whereas the controls maintained peak flexion for about 600 ms. The peak phase lag between knee and hip joint extension in the upward phase was larger for the pain group (-29.7 degrees +/-8.3 degrees vs -17.2 degrees +/-5.5 degrees, P=.003).

CONCLUSION

Women with low back and/or pelvic pain after pregnancy showed different kinematics of lifting. Further research is needed to determine the exact relationship between the altered kinematics and the underlying disorder.

A biomechanical comparison of lifting techniques between subjects with and without chronic low back pain during freestyle lifting and lowering tasks

OBJECTIVE

To evaluate if chronic low back pain patients perform manual material handling tasks differently from control subjects.

DESIGN

Comparative study using a repeated measures design.

BACKGROUND

No study evaluated the lifting technique of back pain patients relative to control subjects during free style lifting and lowering tasks. Previous findings suggest that lowering would be more hazardous than lifting to the low back. It would be interesting to evaluate if chronic low back pain patients behave differently than controls when lifting and lowering.

METHODS

Thirty-three male subjects (18 controls, 15 suffering from non-specific chronic low back pain) participated. A 12-kg box was lifted (freestyle) from the floor to the hips (1) in front (symmetric task) or (2) to a shelf located at 90 degree on the right (asymmetric task) and was lowered back to the floor. A 3D biomechanical analysis involving the assessment of L5/S1 loading, posture of segments, inertial parameters, and EMG was performed.

RESULTS

There was no difference between the groups for postural (trunk and lower limb angles), inertial (trunk velocity and acceleration), and L5/S1 loading (moments and compression) variables. The patients showed abnormally low left lumbar erector spinae (symmetric task, lowering) or high left thoracic erector spinae (all tasks) EMG activation. Significant Group x Action (lifting vs. lowering) interactions were also observed for some inertial and L5/S1 loading variables suggesting that the biomechanical differences detected between lifting and lowering may have a differential influence on the technique used by back pain patients and control subjects.

CONCLUSIONS

The gross lifting technique of back pain patients was unaltered relative to controls but the activation of paraspinal muscles differed, suggesting that a more detailed biomechanical analysis, such as the use of EMG driven models, might be required to reveal lumbar impairments during lifting.

RELEVANCE

To evaluate if chronic low back pain patients use naturally different lifting techniques to prevent pain exacerbation and damaged lumbar tissue overloading.

Spine loading characteristics of patients with low back pain compared with asymptomatic individuals

STUDY DESIGN

Patients with low back pain and asymptomatic individuals were evaluated while performing controlled and free-dynamic lifting tasks in a laboratory setting.

OBJECTIVE

To evaluate how low back pain influences spine loading during lifting tasks.

SUMMARY OF BACKGROUND DATA

An important, yet unresolved, issue associated with low back pain is whether patients with low back pain experience spine loading that differs from that of individuals who are asymptomatic for low back pain. This is important to understand because excessive spine loading is suspected of accelerating disc degeneration in those whose spines are damaged already.

METHODS

In this study, 22 patients with low back pain and 22 asymptomatic individuals performed controlled and free-dynamic exertions. Trunk muscle activity, trunk kinematics, and trunk kinetics were used to evaluate three- dimensional spine loading using an electromyography- assisted model in conjunction with a new electromyographic calibration procedure.

RESULTS

Patients with low back pain experienced 26% greater spine compression and 75% greater lateral shear (normalized to moment) than the asymptomatic group during the controlled exertions. The increased spine loading resulted from muscle coactivation. When permitted to move freely, the patients with low back pain compensated kinematically in an attempt to minimize external moment exposure. Increased muscle coactivation and greater body mass resulted in significantly increased absolute spine loading for the patients with low back pain, especially when lifting from low vertical heights.

CONCLUSIONS

The findings suggest a significant mechanical spine loading cost is associated with low back pain resulting from trunk muscle coactivation. This loading is further exacerbated by the increases in body weight that often accompany low back pain. Patient weight control and proper workplace design can minimize the additional spine loading associated with low back pain.

A longitudinal study of the development of low back pain in an industrial population

STUDY DESIGN

This is a longitudinal study in which industrial workers without chronic low back pain (LBP) were initially assessed with a comprehensive test battery and surveyed every 6 months thereafter for 2 years.

OBJECTIVE

To determine factors that may predispose industrial workers who lift over 5000 kg per shift to LBP.

SUMMARY OF BACKGROUND DATA

Prospective studies are small in number and often limited in breadth or depth of the test battery, methodologic issues, or investigator expertise. There are no prospective studies that focus on a homogeneous work sample of industrial employees.

METHODS

Production workers (n = 149) who volunteered for the 2-year study were assessed using physical measures (e.g., muscular strength, endurance, and flexibility), lifting kinematics (a sagittal plane box lift), and health, lifestyle, and work environment data (paper questionnaires). Follow-up questionnaires were distributed every 6 months for 2 years.

RESULTS

Using self-report of LBP as the main outcome measure, eight variables predicted LBP in this sample with a 75% correct prediction rate. Predictor variables included age, thoracic acceleration during the trunk velocity test, median frequency intercept of electromyography of the right L3 erector spinae, quadriceps strength, quadriceps endurance, self-assessment of fitness, having a confidante, and number of medications currently taken.

CONCLUSION

Results confirmed the multifactorial nature of low back pain and suggest that personal fitness is an important defense against low back pain, even in manual handling lifting tasks.

The comparison of trunk muscles EMG activation between subjects with and without chronic low back pain during flexion-extension and lateral bending tasks

The purpose of the study was to compare the electromyographic (EMG) activity of the trunk muscles between normal subjects and chronic low back pain (CLBP) patients during standardized trunk movements. Thirty-three male subjects (18 normals, 15 suffering from non specific CLBP) aged between 35 and 45 yr participated. A biomechanical analysis involving the recording of EMG signals from 12 trunk muscles, the kinematics of trunk segments and the computation of L5/S1 moments was performed. The subjects performed flexion-extension and lateral bending (left and right) tasks (three complete cycles) with and without a 12 kg load. Between group comparisons were performed on the full cycle average pattern of all biomechanical variables for each task. The reliability of EMG variables was evaluated for 10 subjects (5 normals and 5 CLBP) who performed the tasks on three different days. The reliability of EMG amplitude values was generally excellent for agonist muscles but poor to moderate for antagonists. The EMG amplitude analysis revealed significant differences between groups for some muscles (left lumbar and thoracic erector spinae). The abnormal (asymmetric) EMG patterns detected among CLBP patients were not explained by postural asymmetries.