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

Telerehabilitation for the treatment in chronic low back pain: A randomized controlled trial

IntroductionAlthough there is growth in the approach to telerehabilitation (TLRH) in different pathologies, research on TLRH for the management of low back pain is scarce and controversial. Thus, the purpose of this study was to analyze whether a TLRH program is as effective as a clinical exercise program in improving pain and different functional variables in patients with nonspecific low back pain (NLBP).MethodA single-blind, two-armed randomized controlled trial was carried out with 68 individuals with chronic NLBP. Participants were randomly allocated to either the TLRH group (TG) (n = 34) or the clinic group (CG) (n = 34). The TG received an exercise-based TLRH video and an educational program on the neurophysiology of pain. The CG received the same pain education and exercise program at the clinic facility supervised by a clinician. Both groups performed 2 weekly sessions for 8 weeks. Active movements of the lumbar spine, pain and range of motion, and kinesiophobia were assessed at baseline, at the end of 8 weeks of treatment, and at 3 months.ResultsStatistically significant differences for time-by-group interaction were identified in range of motion of right (F = 11.668; p = 0.001) and left (F = 4.219; p = 0.042) legs when knee extended test is performed; as well as in pain intensity when the same test (F = 5.176; p = 0.043). Moreover, higher pain level during flexion (F = 5.133; p = 0.009) and extension movements (F = 6.335; p = 0.003) in patients with bilateral pain location than those with unilateral or central pain location has been appreciated.ConclusionA TLRH rehabilitation program via mobile app is as effective as the same exercise program supervised in a clinic.

Gender and body height discriminate spinal movement patterns during lifting and lowering tasks

This study aimed to explore the relationships between gender, anthropometrics, and spinal movement patterns (SMP) during lifting and lowering tasks. Thirty adults lifted and lowered a 15 kg-box using a freestyle, squat, and stoop technique. A stepwise segmentation approach, along with the timing of main inflection points of relative angles, was used to distinguish various spinal movement patterns. Temporal multi-segmental interactions were categorised, and their frequencies were analysed based on segments and lifting techniques. SMP's demonstrated varying associations with gender and anthropometric factors during lifting and lowering phases. Notably, during stoop lifting, females tended towards a bottom-up pattern, contrasting with males' preference for a simultaneous pattern. Cluster analysis highlighted the bottom-up pattern in the thoracic spine as the most prominent discriminating factor among females. This SMP categorisation method holds potential for designing tailored manual material handling strategies and re-evaluating therapeutic and exercise programs in occupational, clinical, and sport contexts.

Trunk kinematics and motor unit behavior during different loads and speeds in individuals with and without aberrant movement patterns during active forward bending: A cross-sectional study

BACKGROUND

Instability catch (IC) during active forward bending is an aberrant movement pattern observed in patients with low back pain. Increasing load and speed may show different responses in kinematics and motor unit behavior including peak amplitudes (pAMP) and mean firing rates (mFR).

OBJECTIVES

This study aimed to compare kinematic patterns under different loads and speeds and explored the motor unit behavior in individuals with and without IC.

METHODS

17 participants were classified as having IC and 10 participants were classified as having no IC from clinical observations. Inertial measurement units were used to quantify kinematic parameters, and decomposition electromyography (dEMG) was used to investigate motor unit behavior. Participants performed 2 sets of 1-minute forward bending under low load and low speed (LL), high load and low speed (HL), and low load and high speed (LH) conditions.

RESULTS

Significant between-group differences (P < 0.05) were found in kinematic parameters. Significant within-group changes (P < 0.05) were found between the LL and HL conditions for all kinematic parameters in individuals with IC. Individuals without IC demonstrated significant within-group changes (P < 0.05) between LL and LH in mFR, while individuals without IC showed changes in both pAMP and mFR.

CONCLUSION

These kinematic parameters may represent IC. Changes in motor unit behavior suggest that individuals with and without IC used different strategies to perform this task. Clinicians may consider varying the speed of movement to challenge the trunk neuromuscular control system and design interventions to address motor unit firing rate.

Sex-specific trunk movement coordination in participants with low-back pain and asymptomatic controls

Background

Trunk posture and lumbo-pelvic coordination can influence spinal loading and are commonly used as clinical measures in the diagnosis and management of low-back pain and injury risk. However, sex and pain specific characteristics have rarely been investigated in a large cohort of both healthy individuals and low-back pain patients. It has also been suggested that the motor control of trunk stability and trunk movement variability is altered in individuals with low-back pain, with possible implications for pain progression. Nonetheless, clear links to low-back pain are currently lacking.

Objective

To investigate trunk posture, lumbo-pelvic coordination, trunk dynamic stability and trunk movement variability in an adequately large cohort of individuals with low-back pain and asymptomatic controls and to explore specific effects of sex, pain intensity and pain chronicity.

Methods

We measured lumbo-pelvic kinematics during trunk flexion and trunk dynamic stability and movement variability during a cyclic pointing task in 306 adults (156 females) aged between 18 and 64 years, reporting either no low-back pain or pain in the lumbar area of the trunk. Participants were grouped based on their characteristic pain intensity as asymptomatic (ASY, N = 53), low to medium pain (LMP, N = 185) or medium to high pain (MHP, N = 68). Participants with low-back pain that persisted for 12 weeks or longer were categorized as chronic (N = 104). Data were analyzed using linear mixed models in the style of a two way anova.

Results

Female participants showed a higher range of motion in both the trunk and pelvis during trunk flexion, as well as an increased lumbar lordosis in standing attributed to a higher pelvic angle that persisted throughout the entire trunk flexion movement, resulting in a longer duration of lumbar lordosis. The intensity and chronicity of the pain had a negligible effect on trunk posture and the lumbo-pelvic coordination. Pain chronicity had an effect on trunk dynamic stability (i.e., increased trunk instability), while no effects of sex and pain intensity were detected in trunk dynamic stability and movement variability.

Conclusions

Low-back pain intensity and chronicity was not associated with lumbo-pelvic posture and kinematics, indicating that lumbo-pelvic posture and kinematics during a trunk flexion movement have limited practicality in the clinical diagnosis and management of low-back pain. On the other hand, the increased local instability of the trunk during the cyclic coordination task studied indicates control errors in the regulation of trunk movement in participants with chronic low-back pain and could be considered a useful diagnostic tool in chronic low-back pain.

Altered Movement Coordination during Functional Reach Tasks in Patients with Chronic Low Back Pain and Its Relationship to Numerical Pain Rating Scores

Identifying the effects of pain catastrophizing on movement patterns in people with chronic low back pain (CLBP) has important clinical implications for treatment approaches. Prior research has shown people with CLBP have decreased lumbar-hip ratios during trunk flexion movements, indicating a decrease in the contribution of lumbar flexion relative to hip flexion during trunk flexion. In this study, we aim to explore the relationship between pain catastrophizing and movement patterns during trunk flexion in a CLBP population. Participants with CLBP (N = 98, male = 59, age = 39.1 ± 13.0) completed a virtual reality standardized reaching task that necessitated a progressively larger amount of trunk flexion. Specifically, participants reached for four virtual targets to elicit 15°, 30°, 45°, and 60° trunk flexion in the mid-sagittal plane. Lumbar flexion was derived from the motion data. Self-report measures of numerical pain ratings, kinesiophobia, and pain catastrophizing were obtained. Pain catastrophizing leads to decreased lumbar flexion angles during forward reaching. This effect is greater in females than males.

Lumbo-Pelvic Rhythm Monitoring Using Wearable Technology with Sensory Biofeedback: A Systematic Review

As an essential lower-back movement pattern, lumbo-pelvic rhythm (LPR) during forward trunk flexion and backward return has been investigated on a large scale. It has been suggested that abnormalities in lumbo-pelvic coordination are related to the risk of developing low back disorders. However, considerable differences in the approaches used to monitor LPR make it challenging to integrate findings from those investigations for future research. Therefore, the aim of this systematic review was to summarize the use of wearable technology for kinematic measurement with sensory biofeedback for LPR monitoring by assessing these technologies' specific capabilities and biofeedback capacities and exploring their practical viability based on sensor outcomes. The review was developed following the PRISMA guidelines, and the risk of bias was analyzed using the PREDro and STROBE scales. PubMed, Web of Science, Scopus, and IEEEXPLORE databases were searched for relevant studies, initially returning a total of 528 articles. Finally, we included eight articles featuring wearable devices with audio or vibration biofeedback. Differences in protocols and limitations were also observed. This novel study presents a review of wearable tracking devices for LPR motion-mediated biofeedback for the purpose of correcting lower back posture. More research is needed to determine the long-term effectiveness of these devices, as well as their most appropriate corresponding methodologies.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of low back pain on the kinetics and kinematics of the lumbar spine - a combined in vivo and in silico investigation

Lifting is a significant risk factor for low back pain (LBP). Different biomechanical factors including spinal loads, kinematics, and muscle electromyography (EMG) activities have previously been investigated during lifting activities in LBP patients and asymptomatic individuals to identify their association with LBP. However, the findings were contradictory and inconclusive. Accurate and subject-specific prediction of spinal loads is crucial for understanding, diagnosing, planning tailored treatments, and preventing recurrent pain in LBP patients. Therefore, the present study aimed to estimate the L5-S1 compressive and resultant shear loads in 19 healthy and 17 non-specific chronic LBP individuals during various static load-holding tasks (holding a 10 kg box at hip, chest, and head height) using full-body and personalized musculoskeletal models driven by subject-specific in vivo kinematic/kinetic, EMG, and physiological cross-sectional areas (PCSAs) data. These biomechanical characteristics were concurrently analyzed to identify potential differences between the two groups. Statistical analyses showed that LBP had almost no significant effect on the range of motion (trunk, lumbar, pelvis), PCSA, and EMG. There were no significant differences (p > 0.05) in the predicted L5-S1 loads. However, as the task became more demanding, by elevating the hand-load from hip to head, LBP patients experienced significant increases in both compressive (33 %, p = 0.00) and shear (25 %, p = 0.02) loads, while asymptomatic individuals showed significant increases only in compressive loads (30 %, p = 0.01). This suggests that engaging in more challenging activities could potentially magnify the effect of LBP on the biomechanical factors and increase their discrimination capacity between LBP and asymptomatic individuals.

The relationship between clinical examination measures and ultrasound measures of fascia thickness surrounding trunk muscles or lumbar multifidus fatty infiltrations: An exploratory study

Patients with chronic low back pain (CLBP) exhibit remodelling of the lumbar soft tissues such as muscle fatty infiltrations (MFI) and fibrosis of the lumbar multifidus (LuM) muscles, thickness changes of the thoracolumbar fascia (TLF) and perimuscular connective tissues (PMCT) surrounding the abdominal lateral wall muscles. Rehabilitative ultrasound imaging (RUSI) parameters such as thickness and echogenicity are sensitive to this remodelling. This experimental laboratory study aimed to explore whether these RUSI parameters (LuM echogenicity and fascia thicknesses), hereafter called dependent variables (DV) were linked to independent variables (IV) such as (1) other RUSI parameters (trunk muscle thickness and activation) and (2) physical and psychological measures. RUSI measures, as well as a clinical examination comprising physical tests and psychological questionnaires, were collected from 70 participants with LBP. The following RUSI dependent variables (RUSI-DV), measures of passive tissues were performed bilaterally: (1) LuM echogenicity (MFI/fibrosis) at three vertebral levels (L3/L4, L4/L5 and L5/S1); (2) TLF posterior layer thickness, and (3) PMCT thickness of the fasciae between subcutaneous tissue thickness (STT) and external oblique (PMCTSTT/EO ), between external and internal oblique (PMCTEO/IO ), between IO and transversus abdominis (PMCTIO/TrA ) and between TrA and intra-abdominal content (PMCTTrA/IA ). RUSI measures of trunk muscle's function (thickness and activation), also called measures of active muscle tissues, were considered as independent variables (RUSI-IV), along with physical tests related to lumbar stability (n = 6), motor control deficits (n = 7), trunk muscle endurance (n = 4), physical performance (n = 4), lumbar posture (n = 2), and range of motion (ROM) tests (n = 6). Psychosocial measures included pain catastrophizing, fear-avoidance beliefs, psychological distress, illness perceptions and concepts related to adherence to a home-based exercise programme (physical activity level, self-efficacy, social support, outcome expectations). Six multivariate regression models (forward stepwise selection) were generated, using RUSI-DV measures as dependent variables and RUSI-IV/physical/psychosocial measures as independent variables (predictors). The six multivariate models included three to five predictors, explaining 63% of total LuM echogenicity variance, between 41% and 46% of trunk superficial fasciae variance (TLF, PMCTSTT/EO ) and between 28% and 37% of deeper abdominal wall fasciae variance (PMCTEO/IO , PMCTIO/TrA and PMCTTrA/IA ). These variables were from RUSI-IV (LuM thickness at rest, activation of IO and TrA), body composition (percent fat) and clinical physical examination (lumbar and pelvis flexion ROM, aberrant movements, passive and active straight-leg raise, loaded-reach test) from the biological domain, as well as from the lifestyle (physical activity level during sports), psychological (psychological distress-cognitive subscale, fear-avoidance beliefs during physical activities, self-efficacy to exercise) and social (family support to exercise) domains. Biological, psychological, social and lifestyle factors each accounted for substantial variance in RUSI-passive parameters. These findings are in keeping with a conceptual link between tissue remodelling and factors such as local and systemic inflammation. Possible explanations are discussed, in keeping with the hypothesis-generating nature of this study (exploratory). However, to impact clinical practice, further research is needed to determine if the most plausible predictors of trunk fasciae thickness and LuM fatty infiltrations have an effect on these parameters.

The influence of sedentary behaviour on lumbar-pelvic kinematics during squatting and forward bending among physically active students

Prolonged sitting may involve several mechanisms that make it a risk factor for low back pain. The aim of this study was to investigate lumbar-pelvic kinematics and multifidus muscle (MF) activity during squatting and forward bending in relation to the sedentary behaviour of physically active students. Sixty-three students were divided into two groups according to the time spent in a sitting position during the day: 'high' (>7 h/day); 'low' (≤7 h/day). Lumbar-pelvic ratios, ranges of motion, angular velocities, and MF flexion-relaxation phenomenon were investigated. Data were obtained using the optical motion analysis system, and surface electromyography. The results indicated that lumbar-pelvic ratios during both tasks and velocity of lumbar spine during squatting were significantly greater in the 'high' than in the 'low' sitting group. Muscle activity showed no differences between groups. Prolonged sitting can be considered a factor that slightly, but statistically significantly influences the lumbar-pelvic kinematics in physically active people.Practitioner summary: Lumbar-pelvic kinematics can be altered by prolonged sitting in physically active students. Lumbar-pelvic ratios during squatting and forward bending and lumbar spine velocity during squatting were significantly greater in the 'high' than in the 'low' sitting group. Sedentary behaviour should be considered during an assessment of movement patterns.Abbreviations: BMI: body mass index; ERR: extension-relaxation ratio; FRP: flexion-relaxation phenomenon; FRR: flexion-relaxation ratio; IPAQ: International Physical Activity Questionnaire; LBP: low back pain; METs: metabolic equivalent of tasks; MF: multifidus muscle; PA: physical activity; ROM: range of motion; sEMG: surface electromyography.

Novel force-displacement control passive finite element models of the spine to simulate intact and pathological conditions; comparisons with traditional passive and detailed musculoskeletal models

Passive finite element (FE) models of the spine are commonly used to simulate intact and various pre- and postoperative pathological conditions. Being devoid of muscles, these traditional models are driven by simplistic loading scenarios, e.g., a constant moment and compressive follower load (FL) that do not properly mimic the complex in vivo loading condition under muscle exertions. We aim to develop novel passive FE models that are driven by more realistic yet simple loading scenarios, i.e., in vivo vertebral rotations and pathological-condition dependent FLs (estimated based on detailed musculoskeletal finite element (MS-FE) models). In these novel force-displacement control FE models, unlike the traditional passive FE models, FLs vary not only at different spine segments (T12-S1) but between intact, pre- and postoperative conditions. Intact, preoperative degenerated, and postoperative fused conditions at the L4-L5 segment for five static in vivo activities in upright and flexed postures were simulated by the traditional passive FE, novel force-displacement control FE, and gold-standard detailed MS-FE spine models. Our findings indicate that, when compared to the MS-FE models, the force-displacement control passive FE models could accurately predict the magnitude of disc compression force, intradiscal pressure, annulus maximal von Mises stress, and vector sum of all ligament forces at adjacent segments (L3-L4 and L5-S1) but failed to predict disc shear and facet joint forces. In this regard, the force-displacement control passive FE models were much more accurate than the traditional passive FE models. Clinical recommendations made based on traditional passive FE models should, therefore, be interpreted with caution.

Adjacent segments biomechanics following lumbar fusion surgery: a musculoskeletal finite element model study

PURPOSE

This study exploits a novel musculoskeletal finite element (MS-FE) spine model to evaluate the post-fusion (L4-L5) alterations in adjacent segment kinetics.

METHODS

Unlike the existing MS models with idealized representation of spinal joints, this model predicts stress/strain distributions in all passive tissues while organically coupled to a MS model. This generic (in terms of musculature and material properties) model uses population-based in vivo vertebral sagittal rotations, gravity loads, and an optimization algorithm to calculate muscle forces. Simulations represent individuals with an intact L4-L5, a preoperative severely degenerated L4-L5 (by reducing the disc height by ~ 60% and removing the nucleus incompressibility), and a postoperative fused L4-L5 segment with either a fixed or an altered lumbopelvic rhythm with respect to the intact condition (based on clinical observations). Changes in spine kinematics and back muscle cross-sectional areas (due to intraoperative injuries) are considered based on in vivo data while simulating three activities in upright/flexed postures.

RESULTS

Postoperative changes in some adjacent segment kinetics were found considerable (i.e., larger than 25%) that depended on the postoperative lumbopelvic kinematics and preoperative L4-L5 disc condition. Postoperative alterations in adjacent disc shear, facet/ligament forces, and annulus stresses/strains were greater (> 25%) than those found in intradiscal pressure and compression (< 25%). Kinetics of the lower (L5-S1) and upper (L3-L4) adjacent segments were altered to different degrees.

CONCLUSION

Alterations in segmental rotations mainly affected adjacent disc shear forces, facet/ligament forces, and annulus/collagen fibers stresses/strains. An altered lumbopelvic rhythm (increased pelvis rotation) tends to mitigate some of these surgically induced changes.

Patients with chronic non-specific low back pain have altered movement coordination during functional reaching tasks

BACKGROUND

Identifying altered motor control patterns during functional movements in patients with chronic non-specific low back pain (LBP) has important clinical implications for reducing the risk of recurrence. While prior research has shown that magnitudes of lumbar and hip motion are not altered in patients with chronic non-specific LBP, it is possible that outcomes which describe coordination could provide greater discriminatory information between pathological and healthy movement.

RESEARCH QUESTION

Determine the effect of biological sex and chronic non-specific LBP on coordination between hip and lumbar motion during cyclic and discrete reaching.

METHODS

Twenty participants with chronic non-specific LBP (11 male/9 female, 23.5 ± 4.9 years old) and 21 control participants (12 male/9 female, 22.9 ± 6.1 years old) completed discrete and cyclic reaching tasks to a target in the mid-sagittal plane, while whole-body kinematics were collected using a three-dimensional motion capture system. Movement time, lumbar motion, hip motion, and the ratio between lumbar and hip motion were compared between participants with and without chronic non-specific LBP and between men and women using two-way mixed ANOVAs.

RESULTS

Participants with chronic non-specific LBP had reduced lumbar-hip ratios relative to control participants during both the cyclic (F = 4.779, p = 0.035, η² = 0.114) and discrete tasks (F = 4.743, p = 0.036, η² = 0.119), however group differences were not observed for hip or lumbar excursion during either task (p > 0.05). Participants with chronic non-specific LBP had slower reaching times relative to controls during the discrete reaching task (F = 4.795, p = 0.035, η² = 0.115). No significant effects of sex, and no interactions between group and sex were observed for any outcome.

SIGNIFICANCE

Reduced lumbar-hip ratios during reaching likely reflect a compensatory movement strategy that could play an important role in the development and progression of LBP.

Analysis of the Effect of Wearing Extensible and Non-Extensible Lumbar Belts on Biomechanical Factors of the Sit-to-Stand Movement and Pain-Related Psychological Factors Affecting Office Workers with Low Back Pain

This study aimed to investigate the effects of wearing extensible and non-extensible lumbar belt (LB) on biomechanical factors of the sit-to-stand (STD) movement and pain-related psychological factors affecting office workers with low back pain. Among 30 office workers, 15 with low back pain (LBP) were assigned to the experimental group and 15 healthy adults were assigned to the control group. The participants performed STD movement in random order of three different conditions: without LB (Condition 1), with extensible LB (Condition 2), and with non-extensible LB (Condition 3). Biomechanical variables of STD movement in each condition were measured using a three-dimensional motion analysis system and force plate. Pain-related psychological factors were measured only in the experimental group. Among the biomechanical factors of STD movement, an interaction effect was found in the maximum anterior pelvic tilt angle and total-phase range of motion of the trunk (p < 0.05). Pain intensity, pain-related anxiety, and pain catastrophizing were decreased in the conditions with lumbar belts (Conditions 2 and 3) compared to the condition without LB (Condition 1) (p < 0.05). Extensible and non-extensible lumbar belts engender biomechanically beneficial effects during STD movement in both office workers with LBP and healthy office workers. Further, pain intensity, pain-related anxiety, and pain catastrophizing were decreased in office workers with LBP. Therefore, both types of extensible lumbar belts may be helpful in the daily life of patients with LBP and office workers.

The Theoretical Framework of the Clinical Pilates Exercise Method in Managing Non-Specific Chronic Low Back Pain: A Narrative Review

Simple Summary

Exercise is important in helping people with chronic low back pain to regain wellness. General exercises such as cycling and strength training helps with the condition but require a longer time to achieve meaningful improvements in pain and function. Movement preference is potentially useful in exercise and can help an individual to achieve improvements faster. The Clinical Pilates exercise method uses movement preference and thus is a hybrid of two of the best exercise techniques in managing chronic low back pain. However, current studies in Clinical Pilates are lacking and thus challenge the translation of the technique into clinical practice. Hence, a narrative review of the theory of the Clinical Pilates exercise method is examined, and current literature is reviewed to provide a guide towards successful exercise prescription. A structured approach to physical assessment of human movement is proposed to guide clinicians or researchers involved in exercise prescription to design effective exercises. The structured assessment approach also helps with managing clinical cases with multiple episodes of injuries. Despite limited evidence, the Clinical Pilates exercise method is safe and provides faster and earlier recovery and the same longer term outcomes as general exercises.

Abstract

Exercise plays an important role in rehabilitating people with chronic low back pain. Aerobic exercise and resistance training are general exercise strategies to manage chronic low back pain, but these strategies require longer intervention period to achieve clinical outcomes in pain reduction and functional improvements. Directional preference is recognised as an important exercise strategy in managing low back pain. The Clinical Pilates exercise method leverages on the directional preference of an individual to achieve clinical outcomes faster. Clinical Pilates is a hybrid of two of the best exercise interventions for low back pain, which are general Pilates and the McKenzie method. Due to the scarcity of Clinical Pilates literature, a review of its theory and studies was undertaken to provide a structured guide to the technique in managing people with chronic low back pain. Hypothetical algorithms are developed to support translation into clinical practice and future research studies. These algorithms are useful in the management of complex cases involving multiple directional trauma. Although limited, current evidence suggests that the Clinical Pilates exercise method is safe and provides faster functional recovery in the early stage of rehabilitation and similar longer term outcomes as general exercises.

Biomechanical effects of lumbar fusion surgery on adjacent segments using musculoskeletal models of the intact, degenerated and fused spine

Adjacent segment disorders are prevalent in patients following a spinal fusion surgery. Postoperative alterations in the adjacent segment biomechanics play a role in the etiology of these conditions. While experimental approaches fail to directly quantify spinal loads, previous modeling studies have numerous shortcomings when simulating the complex structures of the spine and the pre/postoperative mechanobiology of the patient. The biomechanical effects of the L4–L5 fusion surgery on muscle forces and adjacent segment kinetics (compression, shear, and moment) were investigated using a validated musculoskeletal model. The model was driven by in vivo kinematics for both preoperative (intact or severely degenerated L4–L5) and postoperative conditions while accounting for muscle atrophies. Results indicated marked changes in the kinetics of adjacent L3–L4 and L5–S1 segments (e.g., by up to 115% and 73% in shear loads and passive moments, respectively) that depended on the preoperative L4–L5 disc condition, postoperative lumbopelvic kinematics and, to a lesser extent, postoperative changes in the L4–L5 segmental lordosis and muscle injuries. Upper adjacent segment was more affected post-fusion than the lower one. While these findings identify risk factors for adjacent segment disorders, they indicate that surgical and postoperative rehabilitation interventions should focus on the preservation/restoration of patient’s normal segmental kinematics.

Impact of load expectations on neuromuscular and postural strategies during a freestyle lifting task in individuals with and without chronic low back pain

Objective

This study aimed to investigate how load expectations modulate neuromuscular and postural strategies in the anticipation of a freestyle lifting task with varying expected loads in individuals with and without chronic low back pain (cLBP).

Methods

Forty-seven participants, 28 with cLBP pain and 19 without, were recruited and completed a series of freestyle lifting trials (3 sets of box lifted for a total of 36 lifts). Verbal cues were used to modulate their expectations about the boxes’ weight: no expectation, lighter or heavier load expectations. Following each set, participants rated their perceived exertion on a visual analog scale. During the lifting protocol, kinematics (time to maximal flexion, angular velocity and joint angles), electromyography muscle activity (erector spinae and quadriceps) and center of pressure displacement were simultaneously recorded.

Results

Results showed that time to maximal knee flexion was modulated by load expectations in both groups (mean lighter load expectations = 1.15 ± 0.32 sec.; mean heavier load expectations = 1.06 ± 0.31 sec.). Results also showed a load expectations X group interaction for that time to maximal hip and lumbar flexion. Time to maximal hip flexion decreased with heavier load expectations (mean lighter load expectations = 1.20 ± 0.36; mean heavier load expectations = 1.16 ± 0.33) for cLBP only. Time to maximal lumbar flexion increased with heavier load expectation (mean lighter load expectations = 1.41 ± 0.27 sec.; mean lighter load expectations = 1.46 ± 0.29 sec.) for participants without LBP. However, no difference in lumbar, hip nor knee angles were observed between groups or conditions. Results highlighted significant load expectation effects for erector spinae electromyography activity, as lower muscle activations was observed for both groups with heavier load expectations (mean = 0.32 ± 0.15), compared to lighter load expectations (mean = 0.52 ± 0.27). Force plates analyses did not reveal any significant load expectation effects.

Conclusion

Present findings showed that load expectations modulate movement strategies and muscle activation similarly but not identically in individuals with chronic low back pain and healthy adults during freestyle lifting. Results of the present study partially differ from previous studies and suggest only minor differences in lifting strategies between healthy individuals and individuals with cLBP experiencing low level of pain and disability. More studies are needed to investigate the potential role of load expectations in the development and persistence of chronic low back pain.

Inter-segmental coordination of the spine is altered during lifting in patients with ankylosing spondylitis: A cross-sectional study

The abnormal inter-segmental coordination of the spine during lifting could be used to monitor disease progression and rehabilitation efficacy in patients with ankylosing spondylitis (AS). This study aimed to compare the inter-segmental coordination patterns and variability of the spine during lifting between patients with AS (n = 9) and control (n = 15) groups.Continuous relative (CRP) and deviation (DP) phases between each segment of the spine (two lumbar and three thorax segments) and lumbosacral joint were calculated. The CRP and DP curves among participants were decomposed into few functional principal components (FPC) via functional principal component analysis (FPCA). The FPC score of CRP or DP of the two groups were compared, and its relationship with the indexes of spinal mobility was investigated.Compared with the control group, the AS patients showed more anti-phase coordination patterns in each relative upper spine segment and lumbosacral joint. In addition, either less or more variation was found in the coordination of each relative lower spine segment and lumbosacral joint during different time periods of lifting for these patients. Some cases were considerably related to spinal mobility.the inter-segmental coordination of the spine was altered during lifting in AS patients to enable movement, albeit inefficient and might cause spinal mobility impairment.

Are there differences in lifting technique between those with and without low back pain? A systematic review

Background and aims

To systemically review the literature to compare freestyle lifting technique, by muscle activity and kinematics, between people with and without low back pain (LBP).

Methods

Five databases were searched along with manual searches of retrieved articles by a single reviewer. Studies were included if they compared a freestyle lifting activity between participants with and without LBP. Data were extracted by two reviewers, and studies were appraised using the CASP tool for case-control studies.

Results

Nine studies were eligible. Heterogeneity did not allow for meta-analysis. Most studies (n = 8 studies) reported that people with LBP lift differently to pain-free controls. Specifically, people with LBP lift more slowly (n = 6 studies), use their legs more than their back especially when initiating lifting (n = 3 studies), and jerk less during lifting (n = 1 studies). Furthermore, the four larger studies involving people with more severe LBP also showed that people with LBP lift with less spinal range of motion and greater trunk muscle activity for a longer period.

Conclusions

People with LBP move slower, stiffer, and with a deeper knee bend than pain-free people during freestyle lifting tasks. Interestingly, such a lifting style mirrors how people, with and without LBP, are often told how to lift during manual handling training. The cross-sectional nature of the comparisons does not allow for causation to be determined.

Implications

The changes described may show embodiment of cautious movement, and the drive to protect the back. There may be value in exploring whether adopting a lifting style closer to that of pain-free people could help reduce LBP.

Sex-dependent differences in lumbo-pelvic coordination for different lifting tasks: A study on asymptomatic adults

During manual material lifting, the sagittal motion is mainly characterized through the lumbo-pelvic coordination, which is quantified by the ratio between the lumbar and hip rotations (L/P ratio). Alteration in the L/P ratio is an important indicator for low back pain (LBP). Previous studies demonstrated sex-dependent differences in LBP prevalence during lifting activities. However, the sex-dependent differences in the L/P ratio during different lifting tasks has to data not been investigated. An optoelectronic system was used to measure the sagittal lumbo-pelvic motion in 10 males and 10 females. Task A was lifting one weight from the ground in front of the body to three target heights with straight knees (A1-3: abdomen, chest and head levels, respectively). Task B was lifting two identical weights from the ground at the sides of the body to three target angles with bended knees (B1-3: arms close and 45° and 90° abducted to the trunk, respectively). Lifts of 10 kg (males and females) and 20 kg (males only) were performed and three phases were investigated: Phase 1 - pure flexion without load, Phase 2 - lifting up weights, Phase 3 - lowering down weights. Females generally displayed a smaller L/P ratio than males. In Phases 2 and 3, the L/P ratio was greater than in Phase 1 for Tasks A and B. The L/P ratio increased with a greater lifting height for Task B, but displayed no difference neither between lifting 10 kg and 20 kg, nor between weight lifting and lowering for both tasks. These results can provide indications for sex-specific recommendations for safer lifting activities.

Support System for the Assessment and Intervention During the Manual Material Handling Training at the Workplace: Contributions From the Systematic Observation

Efficacy of classical manual material handling (MMH) training interventions on back pain prevention at the workplace has been called into question. The way that observation (self-observation or hetero-observation) is used in other areas to create feedback addressed to modify motor activities can justify innovative components for these interventions. However, their implementation and evaluation cannot be done without tackling the methodological challenge of developing a reliable observational instrument to measure manual handling practice during the training process. The aims of this study were: (1) justify and develop an hetero-observation (H-O) instrument to assess changes in the worker behavioral patterns with a level of analysis convenient to derive a parallel version for the systematic self-observation (S-O) during training on MMH; (2) provide evidence on the inter-rater reliability of the H-O instrument; (3) provide evidence on the usability of the S-O instrument and its perceived usefulness; and (4) provide evidence on the benefits that can be derived with the use of the H-O instrument to create feedback based on T-pattern and polar coordinate analysis. A mixed method approach mainly grounded on systematic observation was used. A convenience sample composed by blue-collar workers participated in the study. Based on literature review and expert opinion, the H-O instrument proposed was composed by six dimensions (feet, knee joints, back, elbow joints, load position, and interaction between back tilt and displacement) plus a structural dimension which defined MMH phases. The inter-rater reliability of this instrument was almost perfect for all dimensions using a tolerance level of 2 s (the range of time-unit kappa was from 0.93 to 0.97 and the range of event-based kappa was from 0.82 to 0.9). The usability and usefulness of the S-O instrument was highly valued by workers. Regarding the way to use hetero-observations to create feedback, the paper shows the great potential of T-pattern and polar coordinate analysis. The observational instruments developed combined with these techniques make it possible to characterize the body positions adopted during manual handling performance, and this is crucial to create feedback on performance instead of only feedback on results.

Is there evidence to use kinematic/kinetic measures clinically in low back pain patients? A systematic review

BACKGROUND

Currently, there is a widespread reliance on self-reported questionnaires to assess low back pain patients. However, it has been suggested that objective measures of low back pain patients' functional status should be used to aid clinical assessment. The aim of this study is to systematically review which kinematic /kinetic parameters have been used to assess low back pain patients against healthy controls and to propose clinical kinematic/kinetic measures.

METHODS

PubMed, Embase and Scopus databases were searched for relevant studies. Reference lists of selected studies and hand searches were performed. Studies had to compare people with and without non-specific low back pain while performing functional tasks and report body segment/joint kinematic and/or kinetic data. Two reviewers independently identified relevant papers.

FINDINGS

Sixty-two studies were included. Common biases identified were lack of assessor blinding and sample size calculation, use of samples of convenience, and poor experimental protocol standardization. Studies had small sample sizes. Range of motion maneuvers were the main task performed (33/62). Kinematic/kinetic data of different individual or combination of body segments/joints were reported among the studies, commonest was to assess the hip joint and lumbar segment motion (13/62). Only one study described full body movement. The most commonly reported outcome was range of motion. Statistically significant differences between controls and low back pain groups were reported for different outcomes among the studies. Moreover, when the same outcome was reported disagreements were noted.

INTERPRETATION

The literature to date offers limited and inconsistent evidence of kinematic/kinetic measures in low back pain patients that could be used clinically.

The effect of wearing a lumbar belt on biomechanical and psychological outcomes related to maximal flexion-extension motion and manual material handling

Workers with low back pain (LBP) may benefit from wearing a lumbar belt (LB), but the biomechanical and psychological mechanisms involved are not fully understood. Two types of flexible LB (extensible and non-extensible) were compared to a control condition (no LB) regarding pain-related (pain, fear of pain and catastrophizing) and biomechanical (range of motion - ROM) outcomes related to two tasks: maximal trunk flexion-extension and manual material handling. Healthy controls and participants with LBP were tested. During both tasks, the two LBs reduced the lumbar ROM in participants with LBP in the same way as healthy controls. This was observed even at the beginning of the trunk flexion movement, allowing generalization to many work tasks, that is to say tasks performed with small or deep trunk flexion. The two LBs reduced pain, fear of pain and catastrophizing in subjects with LBP. That may help a gradual re-exposure to physical work activities (disability prevention perspective), or maintaining these activities (secondary prevention perspective), following a LBP episode.

Tactile Feedback can be Used to Redistribute Flexion Motion Across Spine Motion Segments

This experiment investigates the efficacy of tactile feedback in affecting changes to dynamic spine movements. A sample of (n = 24) young, healthy males were assessed while completing targeted spine flexion movements with instruction to minimize stretching of the skin beneath an applied tactile stimulus (liquid bandage). Localized tactile stimuli were placed bilaterally at either lumbar (L4), lower thoracic (T10) or upper thoracic (T4) levels. Results demonstrate that localized tactile feedback elicited a re-distribution of spine flexion movement across spine sub-sections (e.g. lumbar vs. thoracic) and intervertebral segments (e.g. C7/T1 through L5/S1). Further, tactile feedback successfully limited the magnitude of end-range flexion, but did not limit functional mid-range spine flexion. Finally, tactile feedback located in the lower thoracic region (T10) increased thoracic flexion variability; however, tactile feedback located at the T4 and L4 regions had no significant effect on movement variability. These findings provide evidence that spine neuromuscular control patterns can be altered using simple tactile stimuli. In terms of low back injury prevention and/or rehabilitation, the tactile feedback investigated here has apparent utility in limiting recognized mechanical risk factors for low back injury; specifically, the local incidence of flexion at specific spine levels, and the incidence of end-range flexion.

A protocol for clinical trial study of the effect of core stabilization exercises on spine kinematics during gait with and without load in patients with non-specific chronic low back pain

Background

Non-specific chronic low back pain (NCLBP) is a major public health and global socioeconomic burden with a variety of symptoms such as gait abnormality. Trunk stiffness and deep trunk muscles dysfunction known as guarding mechanism in gait are factors leading to abnormal movement pattern of the spine. Anterior load carriage task during gait is also challenged the trunk stability and its movement pattern. It will be therefore of interest to examine the effect of a Core Stabilization Training Program (CSTP) on the trunk and pelvis kinematics including variability and peak displacement during gait with and without load in NCLBP patients.

Methods

Patients with NCLBP will participate in a program containing 16 sessions of CSTP and perceived pain, disability and kinematic will be evaluated with 100 mm visual analog scale (VAS), Oswestry Disability Index (ODI) and motion analyzing system respectively before and after the intervention. Participants will be asked to walk with self-selected comfortable speed for 3 times without load and 3 times with caring a load with hands.

Discussions

We will quantify the effectiveness of CSTP on the kinematic of trunk, lumbar and pelvis during gait. Comparing the kinematic pattern and movement variability using CV_o and CV_p can contribute to better understand the motor control strategy and movement pattern of the spine during an anterior load carriage task between patients with NCLBP and healthy.

Trial registration

IRCT number: IRCT2016080829264N1; pre-result.

The effect of an 8-week stabilization exercise program on the lumbopelvic rhythm and flexion-relaxation phenomenon

BACKGROUND

Lumbar stabilization exercise programs should normalize the aberrant movements patterns often observed in patients with low back pain. This study aimed to determine the effect of an 8-week lumbar stabilization program on EMG/kinematics measures of the aberrant movement patterns in such patients. A secondary goal was to assess the 8-week test-retest reliability of these measures.

METHODS

The patients followed an 8-week lumbar stabilization program while no intervention was carried out on the controls. Before and after this period, kinematics of the spine along with the EMG of paraspinal muscles were recorded during trunk maximal flexion-extension. ANOVAs tested the effect of the intervention in the patients, relative to the controls. Within the patients, correlation of the EMG/kinematics measures with the change in disability and pain following the intervention was investigated.

FINDINGS

A significant reduction in pain (Hedges's g effect size=2.31) and improvement in function (g=1.74) was reported in the patients. While EMG/kinematics measures disclosed impairments in the patients at baseline compared to the controls, no change was observed over the intervention. Nevertheless, the change of lumbar range of motion was positively correlated (r=0.42; P=0.015) with the change in disability.

INTERPRETATION

Although pain and disability decreased following the intervention, the EMG/kinematics measures did not change concomitantly suggesting that the patients learned to stiffen the lumbar spine during the treatment, and this technique was applied even if pain and disability unequivocally decreased after the treatment, which would not necessarily be beneficial to the patient.

Lumbar contribution to the trunk forward bending and backward return; age-related differences

Age-related differences in lumbar contribution to the trunk motion in the sagittal plane were investigated. Sixty individuals between 20-70 years old in five gender-balanced age groups performed forward bending and backward return with slow and fast paces. Individuals older than 50 years old, irrespective of the gender or pace, had smaller lumbar contribution than those younger than this age. The lumbar contribution to trunk motion was also smaller in female participants than male participants, and under fast pace than under the slow pace. Age-related differences in lumbar contributions suggest the synergy between the active and passive lower back tissues is different between those above and under 50 years old, differences that are likely to affect the lower back mechanics. Therefore, detailed modelling should be conducted in future to find the age-related differences in the lower back mechanics for tasks involving large trunk motion. Practitioner Summary: Lumbar contribution to the sagittal trunk motion was observed to be smaller in individuals above 50 years old than those below this age. This could be an indication of a likely change in the synergy between the active and passive lower back tissues, which may disturb the lower back mechanics.

Timing and magnitude of lumbar spine contribution to trunk forward bending and backward return in patients with acute low back pain

Alterations in the lumbo-pelvic coordination denote changes in neuromuscular control of trunk motion as well as load sharing between passive and active tissues in the lower back. Differences in timing and magnitude aspects of lumbo-pelvic coordination between patients with chronic low back pain (LBP) and asymptomatic individuals have been reported; yet, the literature on lumbo-pelvic coordination in patients with acute LBP is scant. A case-control study was conducted to explore the differences in timing and magnitude aspects of lumbo-pelvic coordination between females with (n=19) and without (n=19) acute LBP. Participants in each group completed one experimental session wherein they performed trunk forward bending and backward return at preferred and fast paces. The amount of lumbar contribution to trunk motion (as the magnitude aspect) as well as the mean absolute relative phase (MARP) and deviation phase (DP) between thoracic and pelvic rotations (as the timing aspect) of lumbo-pelvic coordination were calculated. The lumbar contribution to trunk motion in the 2nd and the 3rd quarters of both forward bending and backward return phases was significantly smaller in the patient than the control group. The MARP and the DP were smaller in the patient vs. the control group during entire motion. The reduced lumbar contribution to trunk motion as well as the more in-phase and less variable lumbo-pelvic coordination in patients with acute LBP compared to the asymptomatic controls is likely the result of a neuromuscular adaptation to reduce painful deformation and to protect injured lower back tissues.

Lumbopelvic rhythm in the sagittal plane: A review of the effects of participants and task characteristics

OBJECTIVES

Abnormalities of lumbopelvic coordination have been suggested to relate to risk of developing low back pain. The objective of this study is to review and summarize the findings of studies that have implemented and reported on lumbopelvic rhythm during trunk forward bending and backward return.

METHODS

The PUBMED and CINAHL databases were searched for studies related to LPR using appropriate keywords. The references of each study from the database search were further investigated to identify any missed study.

RESULTS

The findings includes results related to lumbopelvic rhythm, and how it varies due to participant characteristics such as age, gender, and presence of low back pain as well as due to variations in the experimental procedures such as pace of motion, presence of external load, and muscle fatigue.

CONCLUSION

In general, the magnitude of lumbar contribution is smaller in people with low back pain, in the elderly and females, as well as with greater pace of motion, but is larger with greater external load or back muscle fatigue. The compiled data in this review are expected to serve as a foundation for implementation of this kinematic-based measure in the conduct of future research.

Comparison of the different kinematic patterns during lateral bending between subjects with and without recurrent low back pain

BACKGROUND

Lateral bending is a prerequisite for various functional activities of daily life, which require combined three-dimensional motion. Even though a number of studies have evaluated spinal kinematic changes during lateral bending, the literature reveals a lack of data based on limb dominance. The purpose of this study was to compare kinematic angular displacement of the spinal regions for dominant and non-dominant lateral bending in subjects with and without recurrent low back pain.

METHODS

Forty-four right hand dominant individuals with recurrent low back pain (43.1 [17.4] years) and without low back pain (39.7 [18.7] years) participated in this study. All participants were asked to perform trunk lateral bending to the dominant and non-dominant sides with a bar, three times repeatedly. The outcome measures included three-dimensional angular displacements for the three regions of the spine (upper thorax, lower thorax, and lumbar spine).

FINDINGS

Lumbar rotation (degrees) increased to the dominant side in the low back pain group (9.29 [1.06]) compared to the control group (6.20 [1.02]) with increased rotation in the upper thorax as well (t=-2.09, p=0.04). However, the upper thorax rotation increased in the low back pain group to the non-dominant side (t=2.08, p=0.03) and to the dominant side (t=-2.35, p=0.02). There was a group interaction with planes (F=5.82, p=0.02) during lateral bending.

INTERPRETATION

Although lower thorax motion was not different between groups, increased lumbar spine and upper thorax rotations to the dominant side in the low back pain group were evident during lateral bending. This directional asymmetry should be carefully monitored to understand increased lumbar rotation to the dominant side in subjects with recurrent low back pain. The interactions between group and plane explain compensation strategies through increased lumbar rotation to the dominant side with decreased lateral bending of the upper thorax in subjects with recurrent low back pain.

How consistent are lordosis, range of movement and lumbo-pelvic rhythm in people with and without back pain?

BACKGROUND

Comparing movements/postures in people with and without lower back pain (LBP) may assist identifying LBP-specific dysfunction and its relationship to pain or activity limitation. This study compared the consistency in lumbo-pelvic posture and movement (range and pattern) in people with and without chronic LBP (>12 week's duration).

METHODS

Wireless, wearable, inertial measurement units measured lumbar lordosis angle, range of movement (ROM) and lumbo-pelvic rhythm in adults (n = 63). Measurements were taken on three separate occasions: two tests on the same day with different raters and a third (intra-rater) test one to two weeks later. Participants performed five repetitions of tested postures or movements. Test data were captured automatically. Minimal detectable change scores (MDC90) provided estimates of between-test consistency.

RESULTS

There was no significant difference between participants with and without LBP for lordosis angle. There were significant differences for pelvic flexion ROM (LBP 60.8°, NoLBP 54.8°, F(1,63) = 4.31, p = 0.04), lumbar right lateral flexion ROM (LBP 22.2°, NoLBP 24.6° F(1,63) = 4.48, p = .04), trunk right lateral flexion ROM (LBP 28.4°, NoLBP 31.7°, F(1,63) = 5.9, p = .02) and lumbar contribution to lumbo-pelvic rhythm in the LBP group (LBP 45.8 %, F(1,63) = 4.20, NoLBP 51.3 % p = .044). MDC90 estimates for intra and inter-rater comparisons were 10°-15° for lumbar lordosis, and 5°-15° for most ROM. For lumbo-pelvic rhythm, we found 8-15 % variation in lumbar contribution to flexion and lateral flexion and 36-56 % variation in extension. Good to excellent agreement (reliability) was seen between raters (mean r = .88, ICC (2,2)).

CONCLUSION

Comparisons of ROM between people with and without LBP showed few differences between groups, with reduced relative lumbar contribution to trunk flexion. There was no difference between groups for lordosis. Wide, within-group differences were seen for both groups for ROM and lordosis. Due to variability between test occasions, changes would need to exceed 10°-15° for lumbar lordosis, 5°-15° for ROM components, and 8-15 % of lumbar contribution to lumbo-pelvic rhythm, to have 90 % confidence that movements had actually changed. Lordosis, range of movement and lumbo-pelvic rhythm typically demonstrate variability between same-day and different-day tests. This variability needs to be considered when interpreting posture and movement changes.

Facial Expression Overrides Lumbopelvic Kinematics for Clinical Judgements about Low Back Pain Intensity

Background. Through real-time behavioral observation systems, pain behaviors are commonly used by clinicians to estimate pain intensity in patients with low back pain. However, little is known about how clinicians rely on pain-related behaviors to make their judgment. According to the Information Integration Theory (IIT) framework, this study aimed at investigating how clinicians value and integrate information from lumbopelvic kinematics (LK), a protective pain behavior, and facial expression intensity (FEI), a communicative pain behavior, to estimate pain in patients with chronic low back pain (cLBP). Methods. Twenty-one experienced clinicians and twenty-one novice clinicians were asked to estimate back pain intensity from a virtual character performing a trunk flexion-extension task. Results. Results revealed that both populations relied on facial expression and that only half of the participants in each group integrated FEI and LK to estimate cLBP intensity. Among participants who integrated the two pain behaviors, averaging rule predominated among others. Results showed that experienced clinicians relied equally on FEI and LK to estimate pain, whereas novice clinicians mostly relied on FEI. Discussion. The use of additive rule of integration does not appear to be systematic when assessing others' pain. When assessing pain intensity, communicative and protective pain behaviors may have different relevance.

Differences in lumbopelvic rhythm between trunk flexion and extension

BACKGROUND

Trunk flexion and extension have already been found to have different characteristics, such as those in lumbopelvic rhythm. Although a more advanced method of quantifying such rhythm, lumbopelvic continuous relative phase and phase variability have not been used to explore the differences between trunk flexion and extension motions. This information is important since abnormal lumbopelvic coordination patterns increase the risk of low back pain. The current study investigated the differences in lumbopelvic rhythm between trunk flexion and extension, and how the rhythm changed within each of the two motions.

METHODS

Thirteen subjects performed pace-controlled trunk flexion/extension motions in the sagittal plane while lumbar and pelvis kinematics data were recorded, such that the lumbopelvic continuous relative phase and phase variability could be calculated to quantify lumbopelvic rhythm.

FINDINGS

Trunk extension motion had significantly smaller lumbopelvic continuous relative phase and phase variability than flexion motion, which indicated a more in-phase and stable rhythm. Additionally, the lumbopelvic rhythm within trunk extension motion changed from a more in-phase and stable pattern to a more out-of-phase and unstable pattern; by contrast, the opposite change (from out-of-phase and unstable to in-phase and stable) was observed in trunk flexion.

INTERPRETATION

Findings of the current study provided important information about the differences in lumbopelvic rhythm between trunk flexion and extension motions. Quantifying these patterns provides the means for identifying abnormal patterns in a clinical setting, and could serve as normative benchmarks during low back pain rehabilitation plans.

Different coordination and flexibility of the spine and pelvis during lateral bending between young and older adults

This study examined coordination of the spine and pelvis during lateral bending of the trunk in older adults. Thirty-four healthy subjects (17 young and 17 older adults) demonstrated lateral bending at a controlled speed while holding a bar at approximately 180 degrees of shoulder flexion. Kinematic data collection was completed on the thoracic spine, lumbar spine, and pelvis. The coupling angle was calculated to examine the thorax-lumbar, lumbar-pelvis, and thorax-pelvis coordination patterns. The older adults demonstrated a reduced range of motion (ROM) of the lumbar spine, while both groups revealed similar ROM in the thorax and in the pelvis. The coupling angle between the straightening and bending phases was different only for the older adults in the thorax-lumbar (23.4±8.0 vs. -1.6±4.4, p=0.004) and the lumbar-pelvis (65.4±7.2 vs. 86.1±7.8, p=0.001) coordination. However, there was no group difference in the thorax-pelvis coordination. These findings indicate that age-related changes in the lumbar region affect coordination patterns only during the bending phase. The older adults preserved a similar pattern of movement to the young adults during the straightening phase, but the coordination variability of the coupling angles was greater for the older adults than for the young adults. This movement pattern suggests that the older adults lacked consistent trunk control in an attempt to optimize lateral bending coordination.

Lumbopelvic rhythm during trunk motion in the sagittal plane: A review of the kinematic measurement methods and characterization approaches

Lumbopelvic rhythm during trunk forward bending and backward return has been widely investigated to have a better understanding of the pattern of trunk motion, as used in research on low back disorders. Considerable differences in the methods used to measure, and approaches used to characterize the lumbopelvic rhythm hinder the integration of findings of those studies for further research in the future. Thus, the purpose of this review was to summarize the methods for kinematic measurement as well as their characterization approaches for the lumbopelvic rhythm. PUBMED and CINAHL databases were searched for relevant studies. Several types of instruments were found to be used in the reviewed studies, mostly using markers or sensors, which were placed on different parts of spine, with different definitions to measure the lumbar and pelvic motion. Also, various characterization approaches were found to be used, of which some related to the magnitude, while the others to the timing aspects of lumbopelvic rhythm. Such a characterization was either qualitative or quantitative. In addition, the specified characterization approaches were applied on a sample of trunk kinematics data from our lab to demonstrate differences in the outcomes of these approaches.

Trunk and pelvic coordination at various walking speeds during an anterior load carriage task in subjects with and without chronic low back pain

[Purpose] This study compared the coordination patterns of the trunk and pelvis in the transverse plane between healthy subjects and patients with chronic low back pain during an anterior load carriage task at various walking speeds. [Subjects] Ten healthy subjects and 10 patients with chronic low back pain performed an anterior carriage task with a load of 10% body weight at walking speeds of 3.5, 4.5, or 5.5 km/h. [Methods] The trunk and pelvic kinematics were measured by using a motion analysis system. During the anterior carriage task, the continuous relative phase differed significantly between groups with respect to walking speed. [Results] The continuous relative phase was more anti-phase in the chronic low back pain group than the control group. The inter-group continuous relative phase pattern was affected by walking at 5.5 km/h. [Conclusion] Compared to controls, subjects with chronic low back pain are unable to establish an in-phase between the trunk and pelvis from walking at 3.5 to 5.5 km/h during an anterior carriage task.

Chronic low back pain sufferers exhibit freezing-like behaviors when asked to move their trunk as fast as possible

BACKGROUND CONTEXT

The effect of chronic low back pain (CLBP) on the kinematic parameters of trunk motion has received much more interest in this last decade. However, there are no descriptions of the motor strategies that occur when patients perform trunk movements in the three anatomical planes at different pace conditions.

PURPOSE

To investigate motor strategies used by CLBP patients and asymptomatic people while performing different go and back trunk movements in an upright standing position.

STUDY DESIGN

A comparative study.

PATIENT SAMPLE

The control group (CG, n=33) included 14 men and 19 women with no history of low back pain, and the chronic low back pain group (CLBPG, n=49) included 21 men and 28 women.

OUTCOME MEASURES

Kinematic data were analyzed during six trunk movements: flexion, extension, left and right lateral bendings, and rotations under two pace conditions (preferred and fast paces).

METHODS

A three-dimensional optoelectronic motion analysis system was used to assess static (trunk inclinations and base of support) and dynamic (range of motion [ROM] and mean angular velocity of the trunk) parameters during the go and back phases of trunk movements.

RESULTS

In the initial position, CLBPG showed a more forward-tilted trunk inclination (2.1°±1.1°, p=.013) compared with CG. The base of support was significantly higher in CG (+22.7 cm2, p=.009) during the fast pace when compared with the preferred pace. Regardless of the pace condition, ROM and mean angular velocity of the trunk were significantly lower in CLBPG for all examined movements and the pace condition did not significantly alter ROM. At the preferred pace, both groups displayed the same motor strategy: they all went faster during the second phase of movement than during the first phase. However, at the fast pace, while CG was going faster during the first phase than during the second, CLBPG maintained the same motor strategy as at the preferred pace.

CONCLUSIONS

Contrary to CG who changed its motor behavior from a preferred pace to a fast pace, CLBPG exhibited freezing-like behaviors. This original result highlights the importance of studying the velocity. The use of this parameter may improve the diagnosis of CLBP patients and could be a key indicator for treatment progress and long-term monitoring.

Lumbopelvic rhythm during forward and backward sagittal trunk rotations: combined in vivo measurement with inertial tracking device and biomechanical modeling

BACKGROUND

The ratio of total lumbar rotation over pelvic rotation (lumbopelvic rhythm) during trunk sagittal movement is essential to evaluate spinal loads and discriminate between low back pain and asymptomatic population.

METHODS

Angular rotations of the pelvis and lumbar spine as well as their sagittal rhythm during forward flexion and backward extension in upright standing of eight asymptomatic males are measured using an inertial tracking device. The effect of variations in the lumbopelvic ratio during trunk flexion on spinal loads is quantified using a detailed musculoskeletal model.

FINDINGS

The mean of peak voluntary flexion rotations of the thorax, pelvis, and lumbar was 121° (SD 9.9), 53.0° (SD 5.2), and 60.2° (SD 8.6), respectively. The mean lumbopelvic ratios decreased from 2.51 in 0-30° of trunk flexion to 1.34 in 90-120° range during forward bending while it increased from 1.23 in 90-120° range to 2.86 in 0-30° range during backward extension. Variations in the lumbopelvic ratio from 0.5 to 3 (with an interval of 0.25) at any trunk flexion angle generally reduced the L5-S1 compression and shear forces by up to 21 and 45%, respectively. The measured lumbopelvic ratios resulted overall in near-optimal (minimal) L5-S1 compression forces.

INTERPRETATION

A simultaneous rhythm between the lumbar and pelvis movements was found during both forward and backward trunk movements. While the lumbar spine contributed more to the trunk rotation during early and final stages of forward flexion and backward extension, respectively, the pelvis contributed more during final and early stages of forward flexion and backward extension, respectively. Our healthy subjects adapted a lumbopelvic coordination that diminished L5-S1 compression force.

A history of low back pain affects pelvis and trunk mechanics during a sustained lift/lower task

This study compared three-dimensional trunk and pelvis range of motion (ROM) during a sustained asymmetric box lift/lower task between a group with a history of low back pain (HBP, n = 9) and a group with no history of low back pain (NBP, n = 9). Participants lifted an 11-kg box for 10 min at 12 cycles/min from ankle height in front to shelves 45 deg off-centre at waist height. Kinematic data were collected at the beginning (min1), middle (min5) and end of the bout (min9). Two-way analyses of variance were performed for all variables. Pelvis and trunk transverse ROM were similar at min1. By min9, HBP group did not change (31.9 ± 9 deg); however, ROM decreased in NBP group (21.6 ± 6 deg, p < 0.05). Therefore, despite no current pain, the HBP group demonstrated protective lifting mechanics compared to controls. Also discussed are implications for studying lifting paradigms at sub-maximal effort over longer periods of time.

PRACTITIONER SUMMARY

Differences between groups over time demonstrate residual consequences of low back pain (LBP) in a manual materials handling scenario. Individuals with a history of LBP (pain free for 6 months) demonstrated more conservative lifting mechanics towards the end of the bout compared to controls with no history of LBP.

Jack-knife stretching promotes flexibility of tight hamstrings after 4 weeks: a pilot study

Tight hamstrings are reported to be one of the causes of low back pain. However, there have been few reports on effective stretching procedures for the tight hamstrings. The so-called jack-knife stretch, an active-static type of stretching, can efficiently increase the flexibility of tight hamstrings. To evaluate hamstring tightness before and after the 4-week stretching protocol in healthy volunteer adults and patients aged under 18 years with low back pain. For understanding the hamstrings tightness, we measured two parameters including (1) finger to floor distance (FFD) and (2) pelvis forward inclination angle (PFIA). Eight healthy adult volunteers who had no lumbar or hip problems participated in this study (mean age: 26.8 years). All lacked flexibility and their FFD were positive before the experiment. Subjects performed 2 sets of the jack-knife stretch every day for 4 weeks. One set consisted of 5 repetitions, each held for 5 s. Before and during the 4-week experiment, the FFD and PFIA of toe-touching tests were measured weekly. For 17 of the sports players aged under 18, only FFD was measured. In adult volunteers, FFD was 14.1 ± 6.1 cm before the experiment and decreased to -8.1 ± 3.7 cm by the end of week 4, indicating a gain in flexibility of 22.2 cm. PFIA was 50.6 ± 8.2 before the experiment and 83.8 ± 5.8 degrees after. Before and after the experiment, the differences were significant (p < 0.05). For those aged under 18, FFD was 8.1 ± 8.0 and -9.6 ± 6.8, before and after the stretching, respectively. This difference was significant (p < 0.05). The jack-knife stretch is a useful active-static stretching technique to efficiently increase flexibility of tight hamstrings.

A narrative review of evidence-based recommendations for the physical examination of the lumbar spine, sacroiliac and hip joint complex

Non-specific low back pain is a frequent complaint in primary care, but the differential diagnosis for low back pain can be complex. Despite advances in diagnostic imaging, a specific pathoanatomical source of low back pain can remain elusive in up to 85% of individuals. Best practice guidelines recommend that clinicians conduct a focused physical examination to help to identify patients with non-specific low back pain and an evidence-based course of clinical management. The use of sensitive and specific clinical methods to assess the lumbar spine, sacroiliac and hip joints is critical for effective physical examination. Psychosocial factors also play an important role in the evaluation of individuals with low back pain, but are not included in this narrative review of physical examination methods. Physical examination of the lumbar spine, sacroiliac and hip joints is presented, organized around patient position for efficient and effective clinical assessment.

Comparison of three strategies of trunk support during asymmetric two-handed reach in standing

No trunk support (NTS) was compared to a lower trunk support (LTS) of leaning against a worktable and a dynamic upper trunk support (UTS) using postural kinematics, trunk extensor muscle activity and subjective rating of both comfort and effort. Ten females completed 3 repetitions where they lifted 0 and 5 kg load from a symmetrical position at hip-height to a 45° asymmetric position at: i) hip-height and ii) shoulder-height. Human motion capture showed trunk flexion decreased by 12° ± 10 with trunk support with hip-height reach. The table blocked axial rotation of the pelvis which was compensated by an additional 8° ± 6 rotation of the thoracic segment. Surface EMG of the lumbar erector spinae, contralateral to reach, showed the UTS to be almost twice as effective as the LTS with shoulder-height reach with a 30% ± 18 reduction. With hip-height reach, UTS resulted in a smaller reduction equal to 23% ± 27 while the LTS had no effect. Further investigation is needed to determine optimal performance parameters for trunk support with complex, dynamic trunk postures and whether altered kinematics arising from LTS have higher risk of upper back discomfort.

How to lift a box that is too large to fit between the knees

Many studies compared lifting techniques such as stoop and squat lifting. Results thus far show that when lifting a wide load, high back loads result, irrespective of the lifting technique applied. This study compared four lifting techniques in 11 male subjects lifting wide loads. One of these techniques, denoted as the weight lifters' technique (WLT), is characterised by a wide foot placement, moderate knee flexion and a straight but not upright trunk. Net moments were calculated with a 3-D linked segment model and spinal forces with an electromyographic-driven trunk model. When lifting the wide box at handles that allow a high grip position, the WLT resulted in over 20% lower compression forces than the free, squat and stoop lifting technique, mainly due to a smaller horizontal distance between the l5S1 joint and the load. When lifting the wide box at the bottom, none of the lifting techniques was clearly superior to the others. STATEMENT OF RELEVANCE: Lifting low-lying and large objects results in high back loads and may therefore result in a high risk of developing low back pain. This study compares the utility of a WLT, in terms of back load and lumbar flexion, to more familiar techniques in these high-risk lifting tasks.

Whiplash-associated disorders affect postural reactions to antero-posterior support surface translations during sitting

Previous studies have shown that individuals with WAD display decreased postural stability during standing and walking tasks. However, their ability to maintain seated upright posture has never been investigated. The objective of this study was to characterize kinematic and electromyographic postural stabilization patterns in individuals with chronic WAD and to compare these patterns with those in an able-bodied control group. Ten individuals with WAD and an age- and gender-matched group of healthy individuals were exposed to sudden forward and backward support surface translations while they were seated. Neck and trunk muscle activity and angular displacements as well as centers of mass (COMs) linear displacements at four levels of the head and trunk were computed. The displacement onset of the combined head, arms and trunk COM was significantly delayed in persons with WAD. However, their peak trunk angles were smaller and were reached sooner. In the WAD group, the activation onset of the lumbar erector spinae was less affected by perturbation direction and the sternocleidomastoid muscle, a neck flexor, showed a trend towards being activated later, compared to the healthy group. These results suggest that individuals with WAD may alter stretch reflex threshold and/or elicit a learned response for pain avoidance that may be direction-specific. Such findings highlight the importance of assessing both spatial and temporal characteristics across different levels of the spinal musculoskeletal system to evaluate multidirectional postural responses in WAD individuals.