From protection to non-protection: A mixed methods study investigating movement, posture and recovery from disabling low back pain

The Czech version of the back pain attitudes questionnaire: Cross-cultural adaptation and measurement properties analysis

BackgroundAssessing attitudes and beliefs regarding low back pain is an integral component of a person-centered biopsychosocial approach to care.ObjectivesThis study aimed to translate and cross-culturally adapt the Back Pain Attitudes Questionnaire (Back-PAQ) and to evaluate the psychometric properties of both the full 34-item version and its shortened versions.MethodsFollowing recommended guidelines, cross-cultural adaptation process included forward and back translation, expert committee review, and pretesting using Three-Step Test-Interview. The psychometric properties evaluation involved physiotherapists and members of the general public, both with and without low back pain. Factor structure was analyzed using Principal Component Analysis, internal consistency was assessed using Cronbach's α, and test-retest reliability was measured using the Intraclass Correlation Coefficient (ICC).ResultsThe Back-PAQ was translated and culturally adapted to Czech (Back-PAQ-CZ). Five hundred and thirty-nine participants (299 physiotherapists; 240 members of general public) were included for the analysis. No meaningful factor structure was found for the 34-item Back-PAQ-CZ. However, a meaningful factor structure and acceptable Internal Consistency were found for the 10-item and 8-item versions. The test-retest reliability was excellent (ICC2,1 = 0.94), good (ICC2,1 = 0.87) and moderate to good (ICC2,1 = 0.76) for the 34-, 10- and 8-item version, respectively.ConclusionsThe Back-PAQ-CZ and its shortened versions should only be used with an awareness of identified limitations.

Lived and care experiences of young people with chronic musculoskeletal pain and mental health conditions: a systematic review with qualitative evidence synthesis

ABSTRACT

Chronic musculoskeletal pain (CMP) and coexisting mental health conditions impact young people; however, little is known about their lived and care experiences. In a prospectively registered systematic review with qualitative evidence synthesis (PROSPERO: CRD42022369914), we explored the following: (1) lived physical, psychological, and social experiences; and (2) care experiences/preferences of young people living with CMP and mental health conditions. Inclusion criteria: studies using qualitative methods; participants aged 16 to 24 years with CMP and coexisting mental health condition(s); phenomenon explored included lived and/or care experiences. Seven databases were searched (inception to 19-May-2024), study quality was assessed, data were extracted and analysed thematically, and GRADE-CERQual was used to assess confidence in findings. Twenty-two studies (23 reports) were included (>239 participants, 82% women). Lived experiences yielded 4 themes (9 findings): 2-way relationship between CMP and mental health (2 findings, low to moderate confidence); psychosocial implications of CMP (3 findings, very low-moderate confidence); uncertainty about future (2 findings, low-moderate confidence); coping with CMP and mental health conditions (2 findings, low-moderate confidence). Care experiences/preferences yielded 3 themes (8 findings): navigating healthcare systems (2 findings, moderate confidence); receiving appropriate care (3 findings, very low-moderate confidence); point-of-care experiences and care preferences (3 findings, very low-moderate confidence). Chronic musculoskeletal pain and mental health conditions are interconnected, significantly impacting young people's lives, identities, and socialisation, yet services for CMP and mental health are often inadequate and poorly integrated. The mechanisms and interplay of CMP and mental health require deeper exploration, including how young people may be better supported with personalised, holistic, developmentally and/or life-stage-appropriate integrated care.

Postural asymmetry in low back pain - a systematic review and meta-analysis of observational studies

PURPOSE

Systematic review and meta-analysis to examine common static postural parameters between participants with and without low back pain (LBP).

METHODS

Systematic search on the PubMed, CINAHL, Embase and SCOPUS databases using keywords 'posture' and 'low back pain'. Observational studies comparing static postural outcomes (e.g. lumbar lordosis) between participants with and without LBP were included. Two independent reviewers conducted screening, data extraction and quality assessment. Methodological quality was assessed using Joanna Briggs Institute's critical appraisal tools.

RESULTS

Studies included in review = 46 (5,097 LBP; 6,974 controls); meta-analysis = 36 (3,617 LBP; 4,323 controls). Quality of included studies was mixed. Pelvic tilt was statistically significantly higher in participants with LBP compared to controls (n = 23; 2,540 LBP; 3,090 controls; SMD:0.23, 95%CI:0.10,0.35, p < 0.01, I2=72%). Lumbar lordosis and sacral slope may be lower in participants with LBP; pelvic incidence may be higher in this group; both were not statistically significant and the between study heterogeneity was high. Thoracic kyphosis and leg length discrepancy showed no difference between groups.

CONCLUSIONS

Lumbopelvic mechanisms may be altered in people with LBP, but no firm conclusions could be made. Pelvic tilt appeared to be increased in participants with LBP. Postural variable measurement needs standardisation. Better reporting of study characteristics is warranted.

Relationships Between Changes in Forward Bending, Pain Catastrophizing, and Pain Self-Efficacy During Cognitive Functional Therapy for People With Chronic Low Back Pain

OBJECTIVE: To investigate whether improvements in forward bending were related to reductions in pain catastrophizing (PC) and improvements in pain self-efficacy (PSE) in people with chronic low back pain (CLBP) who were undergoing cognitive functional therapy (CFT). DESIGN: Longitudinal observational study. METHODS: Two hundred sixty-one participants with CLBP received CFT. Forward bending was assessed at each treatment session over 13 weeks (average of 4.3 time points per participant [range, 1-8]). Inertial measurement units placed on T12 and S2 measured spinal range of movement (ROM) and velocity. Participants completed the Pain Catastrophizing Scale and the Pain Self-Efficacy Questionnaire online at 0, 3, 6, and 13 weeks. Multivariate, multilevel models evaluated the associations between individual rates of change over time for 3 spinal movement measures (trunk velocity, trunk ROM, and lumbar ROM) as well as PC/PSE. RESULTS: Strong correlations were observed for increased trunk velocity with reduced PC (r = -0.56; 95% confidence interval [CI]: -0.82, -0.01) and increased PSE (r = 0.63; 95% CI: 0.18, 0.87). There was no evidence of an association between changes in trunk ROM and PC (r = -0.06; 95% CI: 0.38, 0.28) or PSE (r = 0.36; 95% CI: -0.27, 0.65) as well as no evidence of an association between lumbar ROM and PC (r = -0.07; 95% CI: -0.63, 0.55) or PSE (r = 0.16; 95% CI: -0.49, 0.69). CONCLUSION: Improvements in PC and PSE were strongly correlated with increased trunk velocity-but not trunk or lumbar ROM-in people with CLBP who were undergoing CFT. These findings are consistent with CFT that explicitly trains "nonprotective" spinal movement in conjunction with positively reframing pain cognitions. J Orthop Sports Phys Ther 2025;55(4):1-11. Epub 12 March 2025. doi:10.2519/jospt.2025.13114.

Central mechanisms of muscle tone regulation: implications for pain and performance

Muscle tone represents a foundational property of the motor system with the potential to impact musculoskeletal pain and motor performance. Muscle tone is involuntary, dynamically adaptive, interconnected across the body, sensitive to postural demands, and distinct from voluntary control. Research has historically focused on pathological tone, peripheral regulation, and contributions from passive tissues, without consideration of the neural regulation of active tone and its consequences, particularly for neurologically healthy individuals. Indeed, simplistic models based on the stretch reflex, which neglect the central regulation of tone, are still perpetuated today. Recent advances regarding tone are dispersed across different literatures, including animal physiology, pain science, motor control, neurology, and child development. This paper brings together diverse areas of research to construct a conceptual model of the neuroscience underlying active muscle tone. It highlights how multiple tonic drive networks tune the excitability of complex spinal feedback circuits in concert with various sources of sensory feedback and in relation to postural demands, gravity, and arousal levels. The paper also reveals how tonic muscle activity and excitability are disrupted in people with musculoskeletal pain and how tone disorders can lead to marked pain and motor impairment. The paper presents evidence that integrative somatic methods address the central regulation of tone and discusses potential mechanisms and implications for tone rehabilitation to improve pain and performance.

The general public as well as physiotherapists evaluate spinal flexion as dangerous regardless of their own low back pain history

BACKGROUND

Maladaptive fear of movement in individuals with low back pain may be associated with worse clinical outcomes.

OBJECTIVE

To explore beliefs about the perceived dangers regarding different spinal postures within the Czech Republic.

DESIGN

Exploratory cross-sectional study including physiotherapists and members of the general public.

METHODS

Self-reported perceived safety/danger of "straight" and "flexed" spinal postures regarding 1) sitting, 2) lifting of light and 3) heavy object from the floor based on three pairs of photographs was measured using numeric rating scales (0-10, safe to dangerous) without any given context and in the context of low back pain. The sum of differences between the ratings of flexed and straight postures were used to calculate Bending Safety Beliefs Thermometer (BSBThermometer) total score potentially ranging -60‒60 (higher values indicates evaluation of flexed spinal postures as more dangerous in comparison to straight postures).

RESULTS

760 participants were included in the analysis. The mean BSBThermometer total score was 31.1 (SD 16.1) and higher scores were positively associated with being women (b = 14.8, 95% CI [9.9-19.8]); non-medical profession (b = 24.7, 95% CI [15.2-34.2]); age (b = 0.38, 95% CI [0.16-0.6]; and their interactions. There was no significant association with current low back pain status or history of low back pain.

CONCLUSIONS

On average, participants evaluated "flexed" spinal postures as significantly more dangerous when compared with "straight" spinal postures, with only subgroups of physiotherapists scoring lower than the general public. Clinically, these beliefs could be targeted by individualized education, exposure-based interventions and public campaigns; however, further research is required.

A Prospective Qualitative Inquiry of Patient Experiences of Cognitive Functional Therapy for Chronic Low Back Pain During the RESTORE Trial

Cognitive functional therapy (CFT) is a person-centered biopsychosocial physiotherapy intervention that has recently demonstrated large, durable effects in reducing pain and disability in people with chronic low back pain (CLBP). However, exploration of the treatment process from the patients' perspectives, including the process of gaining control and agency over CLBP, is relatively understudied in this patient population. This qualitative study explored the experiences of eight participants from the RESTORE trial through longitudinally following their experiences, including interviews during baseline, mid-treatment, end-treatment, and 12-month follow-up. Data were analyzed according to a narrative approach. Findings described the overarching narrative themes of "The Journey to Self-Management." Within this overarching narrative, four distinct narratives were identified, beginning with "Left High and Dry," capturing the experience of isolation and abandonment with CLBP before commencing CFT, and concluding with three narratives of the experience of CFT from the start of treatment through to the 12-month follow-up. These included "Plain, Smooth Sailing," describing a journey of relative ease and lack of obstacles; "Learning the Ropes and Gaining Sea Legs," capturing an iterative process of learning and negotiating setbacks; and "Sailing Through Headwinds," describing the experience of struggle to gain agency and control over CLBP through CFT. Clinicians treating individuals with CLBP can use these insights to more effectively facilitate self-management, and people living with CLBP may find resonance from the narrative themes to support their journeys.

Can training to dissociate trunk and pelvic motion influence thorax-pelvis coordination and lumbar spine dynamic stability?

BACKGROUND

The large number of articulating joints within the spinal column provides an abundance of options to control its movement. However, the ability of individuals to consciously manipulate these movement options is poorly understood.

OBJECTIVES

To determine if short-term training can improve the ability to consciously dissociate motion between the pelvis and thorax during repetitive pelvic tilting movements.

DESIGN

Cross-over design with young healthy individuals.

METHOD

Seventeen participants performed trials consisting of 35 continuous lift/lowers followed by 35 continuous anterior/posterior pelvic tilts while spine kinematics were recorded. Participants then underwent a 20-min training protocol designed to improve the control of pelvic motion and in particular the dissociation of pelvic and trunk motion. Post-training, the continuous pelvic tilt and lift/lower trials were repeated. Thorax-pelvis movement coordination was analyzed via vector coding and lumbar spine local dynamic stability was analyzed via Lyapunov exponents. Participants were grouped as being either high or low skill movers based on their ability to perform the pre-training pelvic tilt movements.

RESULTS

The low skill movement group demonstrated statistically significant increases in the time spent using in-phase pelvic dominant (p = 0.028) and anti-phase pelvic dominant (p = 0.043) coordination patterns during the pelvic tilt movements after the completion of the training protocol. The high skill movement group showed no differences in their movement patterns post-training.

CONCLUSIONS

Short-term training, targeted to improve the ability to dissociate pelvic from thorax motion, had a beneficial effect on the group of individuals who initially lacked skill performing the pelvic tilting task.

Attentional Distractions Do Not Influence Lumbar Spine Local Dynamic Stability during Repetitive Flexion-Extension Movements

The association between low back pain and lumbar spine local dynamic stability (LDS) appears to be modulated by if and how someone catastrophizes about pain, suggesting that the cognitive perceptions of pain may influence an individual's ability to control lumbar spine motion. Previous work also demonstrates that directing cognitive resources and attentional focus can influence movement performance. Therefore, we aimed to examine whether distracting attentional focus would influence lumbar spine LDS during repetitive flexion-extension movements. Sixteen participants performed repetitive spine flexion-extension movements under two baseline conditions (pre- and post-), and while attentional focus was distracted by either an external sensory stimulus or a cognitive-motor dual-task, both targeted at the hands. Lumbar spine LDS was examined over 30 continuous movement repetitions using maximum Lyapunov exponents. In comparison to both Baseline and Post-Baseline trials, the perceived mental workload was significantly elevated during the cognitive-motor dual-task trial but not the external sensory stimulus trial. The only statistically significant effect on LDS occurred in the Post-Baseline trial, where LDS was higher than in the cognitive-motor dual-task. In combination with previous work, these findings suggest that distracting attentional focus during repetitive lumbar spine flexion-extension movements does not have a negative influence on lumbar spine LDS.

The relationships between spinal amplitude of movement, pain and disability in low back pain: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

The role of spinal movement alterations in low back pain (LBP) remains unclear. This systematic review and meta-analyses examined the relationships between spinal amplitude of movement, disability and pain intensity in patients with LBP.

DATABASES AND DATA TREATMENT

We searched PubMed, CINAHL, Embase, Pedro and Web of Science for relevant articles until 14th March 2023. Risk of bias was assessed with the Quality in Prognostic Studies Tool. We analysed the relationships between amplitude of movement, disability and pain intensity with standard correlational meta-analyses and meta-analytic structural equation modelling (MASEM) in cross-sectional and longitudinal data.

RESULTS

A total of 106 studies (9001 participants) were included. In cross-sectional data, larger amplitude of movement was associated with lower disability (pooled coefficient: -0.25, 95% confidence interval: [-0.29 to -0.21]; 69/5899 studies/participants) and pain intensity (-0.13, [-0.17 to -0.09]; 74/5806). An increase in amplitude of movement was associated with a decrease in disability (-0.23, [-0.31 to -0.15]; 33/2437) and pain intensity (-0.25, [-0.33 to -0.17]; 38/2172) in longitudinal data. MASEM revealed similar results and, in addition, showed that amplitude of movement had a very small influence on the pain intensity-disability relationship.

CONCLUSIONS

These results showed a significant but small association between amplitude of movement and disability or pain intensity. Moreover, they demonstrated a direct association between an increase in amplitude of movement and a decrease in pain intensity or disability, supporting interventions aiming to reduce protective spinal movements in patients with LBP.

SIGNIFICANCE

The large meta-analyses performed in this work revealed an association between reductions in spinal amplitude of movement and increased levels of disability and pain intensity in people with LBP. Moreover, it highlighted that LBP recovery is associated with a reduction in protective motor behaviour (increased amplitude of movement), supporting the inclusion of spinal movement in the biopsychosocial understanding and management of LBP.

Understanding Discrepancies in a Person's Fear of Movement and Avoidance Behavior: A Guide for Musculoskeletal Rehabilitation Clinicians Who Support People With Chronic Musculoskeletal Pain

BACKGROUND: Generic self-report measures do not reflect the complexity of a person's pain-related behavior. Since variations in a person's fear of movement and avoidance behavior may arise from contextual and motivational factors, a person-centered evaluation is required-addressing the cognitions, emotions, motivation, and actual behavior of the person. CLINICAL QUESTION: Most musculoskeletal rehabilitation clinicians will recognize that different people with chronic pain have very different patterns of fear and avoidance behavior. However, an important remaining question for clinicians is "How can I identify and reconcile discrepancies in fear of movement and avoidance behavior observed in the same person, and adapt my management accordingly?" KEY RESULTS: We frame a clinical case of a patient with persistent low back pain to illustrate the key pieces of information that clinicians may consider in a person-centered evaluation (ie, patient interview, self-report measures, and behavioral assessment) when working with patients to manage fear of movement and avoidance behavior. CLINICAL APPLICATION: Understanding the discrepancies in a person's fear of movement and avoidance behavior is essential for musculoskeletal rehabilitation clinicians, as they work in partnership with patients to guide tailored approaches to changing behaviors. J Orthop Sports Phys Ther 2023;53(5):1-10. Epub: 9 March 2023. doi:10.2519/jospt.2023.11420.

Distinction of non-specific low back pain patients with proprioceptive disorders from healthy individuals by linear discriminant analysis

The central nervous system (CNS) dynamically employs a sophisticated weighting strategy of sensory input, including vision, vestibular and proprioception signals, towards attaining optimal postural control during different conditions. Non-specific low back pain (NSLBP) patients frequently demonstrate postural control deficiencies which are generally attributed to challenges in proprioceptive reweighting, where they often rely on an ankle strategy regardless of postural conditions. Such impairment could lead to potential loss of balance, increased risk of falling, and Low back pain recurrence. In this study, linear and non-linear indicators were extracted from center-of-pressure (COP) and trunk sagittal angle data based on 4 conditions of vibration positioning (vibration on the back, ankle, none or both), 2 surface conditions (foam or rigid), and 2 different groups (healthy and non-specific low back pain patients). Linear discriminant analysis (LDA) was performed on linear and non-linear indicators to identify the best sensory condition towards accurate distinction of non-specific low back pain patients from healthy controls. Two indicators: Phase Plane Portrait ML and Entropy ML with foam surface condition and both ankle and back vibration on, were able to completely differentiate the non-specific low back pain groups. The proposed methodology can help clinicians quantitatively assess the sensory status of non-specific low back pain patients at the initial phase of diagnosis and throughout treatment. Although the results demonstrated the potential effectiveness of our approach in Low back pain patient distinction, a larger and more diverse population is required for comprehensive validation.