Sensorimotor and body perception assessments of nonspecific chronic low back pain: a cross-sectional study

Body perception outcome measures in chronic non-specific low back pain: A systematic review of measurement properties using the COSMIN approach

Chronic low back pain (CLBP) is a highly prevalent health problem. Recent research has suggested that disruption of body perception might contribute to the problem and represent a target for treatment. Valid and reliable outcome measures are required to understand the relationship between disrupted body perception and clinical status. This systematic review aimed to identify patient reported outcome measures (PROMs) used to assess body perception disruption in people with CLBP and evaluate their psychometric properties. Five databases were searched for studies investigating the psychometric properties of PROMs designed to assess body perception in people with CLBP. The appraisal of the methodological quality and measurement properties adhered to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology. Sixteen studies were included, evaluating two PROMs: the Fremantle Back Awareness Questionnaire (FreBAQ) and the Body Awareness Rating Questionnaire (BARQ). The studies included data from 2545 participants, comprising 1694 individuals with CLBP. The following measurement properties were investigated: content validity; structural validity; internal consistency; cross-cultural validity; test-retest reliability; measurement error and construct validity. While there is evidence for test-retest reliability and construct validity, neither questionnaire demonstrated adequate content validity and there was a low level of evidence for sufficient internal consistency. Consequently, both the FreBAQ and BARQ were classified as 'B', indicating their potential for recommendation, contingent upon further research to evaluate their quality. Future research should address identified limitations of the questionnaires, particularly content validity. This will lead to the development of more useful tools to measure body perception in the CLBP population. Perspective This article presents an evaluation of the psychometric properties of patient reported outcome measures used to assess body perception in individuals with chronic low back pain. These tools could potentially help clinicians identify and address body perception distortions in people with chronic low back pain, leading to effective management strategies.

Ageing and higher BMI explain movement control impairment distinctly better than chronic pain and its contributing factors: A cross-sectional study of 161 subjects with chronic low back pain and 42 pain-free controls

BackgroundAssessment, diagnosis, and treatment of motor control impairments are among the most widely implemented management strategies for chronic low back pain (CLBP). Low back movement control tests described by Luomajoki et al. are reliable and valid for assessing the presence and severity of motor control impairment. However, very little is known about the importance of demographic and well-established CLBP contributing factors in explaining the presence and severity of any type of motor control impairment.ObjectiveThe study objectives were to evaluate the associations of the presence and the severity of movement control impairment with age, gender, BMI, CLBP and its intensity and duration, postural stability, self-reported central sensitization, kinesiophobia, and CLBP-related disability with logistic and ordinal regressions and Wald chi-squared tests.MethodsThis cross-sectional study included 161 subjects with CLBP and 42 pain-free controls. The study was carried out in single private chiropractic clinic.ResultsHigher age and BMI were distinctly greater associated with a higher presence and severity of movement control impairment compared to the pain-related factors, namely the CLBP or its intensity or duration, central sensitization, kinesiophobia, and CLBP-related disability.ConclusionsResults highlight the importance of considering demographic factors, such as age and BMI, when interpreting motor control impairment findings. Accordingly, the findings challenge the validity of testing motor control impairment in the management of CLBP.

Self-reported questionnaires assessing body perception disturbances in adults with chronic non-cancer pain: a scoping review

Introduction

Body perception disturbances (BPD) are well documented in certain chronic pain populations [e.g., complex regional pain syndrome (CRPS)], while being far less studied in chronic pain as a general condition. The aims of this scoping review are to identify the self-reported questionnaires used to assess BPD in individuals with chronic non-cancer pain and to refine the definition of the BPD construct as used in these questionnaires.

Methods

A search strategy focusing on the concepts of "chronic pain", "body perception" and "questionnaire" was used across four databases. Each record was screened for eligibility by two independent reviewers, and data extraction was performed by one reviewer and validated by a second reviewer.

Results

Eighty-seven studies were included, comprising 18 different questionnaires-either directly related to BPD or containing relevant items. The three most commonly used questionnaires were the Bath Body Perception Disturbance Scale, the Fremantle Back Awareness Questionnaire, and the Neurobehavioral Questionnaire. Appraisal of the construct derived from the questionnaire items identified five main facets: size, shape, cognitive neglect-like symptoms, proprioceptive awareness, and agency, along with 11 other less frequently addressed facets. The most represented clinical populations were CRPS (40 studies) and chronic low-back pain (20 studies).

Discussion

A variety of self-reported questionnaires are available to assess BPD, but most are diagnosis- or body-region specific. To better assess BPD in individuals with chronic non-cancer pain, a consensus on the general definition and the key facets of the construct is needed.

Body image at the trunk: An investigation into externally referenced width perception and picture mapping

Body image is a conscious representation of the body, encompassing how our body feels to us. Body image can be measured in a variety of ways, including metric and depictive measures. This study sought to assess body image at the trunk by investigating, and comparing, a metric and depictive measure. Sixty-nine healthy participants estimated their thorax, waist, and hip width by externally referencing mechanical calipers. Participants were also asked to select the true image of their trunk from a random display of nine images containing the true image and incrementally shrunken or enlarged images. Participants demonstrated evidence of thorax and waist width overestimation in the width perception task, with no evidence for hip misestimation. For the picture mapping task, the majority of participants were inaccurate. In participants who were inaccurate, approximately equal proportions underestimated and overestimated their trunk width. The two tasks were found to be independent of each other. Distortions, or inaccuracies, were apparent in a metric measure, and inaccuracies also present in a depictive measure, of body image at the trunk for healthy participants. An overestimation bias was apparent in the metric, but not depictive, task. No relationship was found between tasks..

Body Image Measured via the Fremantle Awareness Questionnaire in Individuals With and Without Pain: A Systematic Review and Meta-Analysis

Research suggests that pain negatively affects body image, and body image may also influence reported pain levels. This review aims to summarize the literature on differences in body image distortion between individuals with pain compared to pain-free individuals. The review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 statement and an a priori preregistered protocol. The literature was searched using 5 electronic databases. Studies assessing body image with the Fremantle Awareness Questionnaire (FAQ) in individuals with and without pain were eligible for inclusion. Screening and selection of eligible studies were performed by independent reviewers. Methodological quality was assessed with the Joanna Briggs Institute critical appraisal tool. Meta-analyses, meta-correlations, and metamean analyses were performed using random-effect models. The primary outcome was the FAQ score; secondary outcomes were reported pain variables. Data from individuals with pain (n = 2277) and without pain (n = 615) were summarized. Significant body image distortions were found in individuals with pain compared to individuals without pain. Compared to pain-free individuals, the pain group rated significantly higher in the FAQ when experiencing back pain (standardized mean differences=1.33, 95% confidence interval=.88-1.77) or other body parts (standardized mean differences=1.25, 95% confidence interval=.51-1.99). The results of meta-correlation analyses confirmed the positive relationship between body image distortion and pain intensity (r = .31), pain at rest (r = .31), or pain during movement (r = .36), but not for pain duration. A difference in mean FAQ results was observed between individuals with pain in different areas (knee and back). PERSPECTIVE: This review confirms differences in body image distortion between pain and pain-free individuals. Pain intensity was correlated with altered body perception, but not pain duration. A moderate correlation was observed between body image distortion and reported pain variables. Body image was more impaired by knee pain than back pain. REGISTERED PROTOCOL AT PROSPERO: CRD42022309937; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022309937.

Clinically assessed lumbopelvic sensorimotor control tests in low back pain: are they actually valid? A systematic review according to COSMIN guidelines

BACKGROUND

Impairments in lumbopelvic sensorimotor control (SMC) are thought to be one of the underlying mechanisms for the recurrence and persistence of low back pain (LBP). As such, lumbopelvic SMC tests are frequently included in the clinical examination of patients with LBP.

OBJECTIVE

To evaluate convergent and known-groups validity of clinically assessed lumbopelvic SMC tests in patients with LBP according to COSMIN guidelines.

DESIGN

Systematic review METHODS: Five electronic databases were searched until December 2023. Studies examining convergent or known-groups validity of lumbopelvic SMC tests assessed via inspection or palpation in patients with LBP were included. Known-groups validity had to be assessed between patients with LBP and pain-free persons. Two independent researchers appraised risk of bias and quality of evidence (QoE) using the COSMIN Risk of Bias checklist and modified GRADE approach, respectively. Results for known-groups validity were reported separately for single tests and test-clusters.

RESULTS

Twelve studies (946 participants) were included. Three studies investigated convergent validity of three single tests. Regarding known-groups validity, six studies evaluated six single tests and four studies investigated two test-clusters. For only one test, both convergent and known-groups were assessed. The QoE for tests showing sufficient convergent or known-groups validity was (very) low, whereas QoE was moderate for single tests or test-clusters with insufficient known-groups validity.

CONCLUSION

All clinically assessed lumbopelvic SMC tests with sufficient convergent or known-groups validity had (very) low QoE. Therefore, test outcomes should be interpreted cautiously and strong reliance on these outcomes for clinical decision-making can currently not be recommended.

The Fremantle Back Awareness Questionnaire: cross-cultural adaptation, reliability, and validity of the Italian version in people with chronic low back pain

BACKGROUND AND AIM

There is evidence to suggest that assessing back-specific altered self-perception may be useful when seeking to understand and manage low back pain (LBP). The Fremantle Back Awareness Questionnaire (FreBAQ) is a patient-reported measure of back-specific body perception that has never been adapted and psychometrically analysed in Italian. Hence, the objectives of this research were to cross-culturally adapt and validate the Italian version of this outcome measure (namely, the FreBAQ-I), to make it available for use with Italians suffering from chronic LBP.

METHODS

The FreBAQ-I was developed by forward and backward translation, review by a committee skilled in patient-reported measures and test of the pre-final version to assess its clarity, acceptability, and relevance. The statistical analyses examined: structural validity based on Rasch analysis; hypotheses testing by investigating correlations of the FreBAQ-I with the Roland Morris Disability Questionnaire (RMDQ), a pain intensity numerical rating scale (PI-NRS), the Pain Catastrophising Scale (PCS), and the Tampa Scale of Kinesiophobia (TSK) (Pearson's correlations); reliability by internal consistency (Cronbach's alpha) and test-retest repeatability (intraclass correlation coefficient, ICC (2,1)); and measurement error by determining the minimum detectable change (MDC). After the development of a consensus-based translation of the FreBAQ-I, the new outcome measure was delivered to 100 people with chronic LBP.

RESULTS

Rasch analysis confirmed the substantial unidimensionality and the structural validity of the FreBAQ-I. Hypothesis testing was considered good as at least 75% of the hypotheses were confirmed; correlations: RMDQ (r = 0.35), PI-NRS (r = 0.25), PCS (r = 0.41) and TSK (r = 0.38). Internal consistency was acceptable (alpha = 0.82) and test-retest repeatability was excellent (ICC (2,1) = 0.88, 95% CI: 0.83, 0.92). The MDC95 corresponded to 6.7 scale points.

CONCLUSION

The FreBAQ-I was found to be a unidimensional, valid, and reliable outcome measure in Italians with chronic LBP. Its application is advised for clinical and research use within the Italian speaking community.

Identical movement control exercises with and without synchronized breathing for chronic non-specific low back pain:A randomized pilot trial

BACKGROUND

Exercise is a first-line treatment for chronic non-specific low back pain (CNSLBP). Exercise combined with specific breathing techniques have the potential to improve multifactorial outcomes. No previous studies, however, have compared outcomes between identical exercises with or without a specific breathing protocol in a uniform clinical study setting.

OBJECTIVES

1) To investigate the feasibility of combining synchronized breathing with movement control exercises and evaluate eligibility criteria, randomization procedures, and dropout rates. 2) To study the preliminary efficacy of the interventions on multifactorial outcome measures.

METHODS

Thirty subjects with CNSLBP were randomized into two groups. Both groups had four contact clinic visits where they received personalized home movement control exercises to practice over two months. The experimental group included a movement control exercise intervention combined with synchronized breathing techniques. Trial registration number: NCT05268822.

RESULTS

Feasibility was demonstrated by meeting the recruitment goal of 30 subjects within the pre-specified timeframe with enrolment rate of 24.8% (30/121). Synchronized breathing techniques were successfully adhered by participants. Home exercise adherence was nearly identical between the groups without any adverse events. Preliminary efficacy findings on pain intensity, disability, and self-efficacy in the experimental group exceeded the minimal clinically important difference. No such findings were observed in any outcome measures within the control group. Overall, multifactorial differences were consistent because nine out of eleven outcome measures showed greater improvements for the experimental group.

CONCLUSION

The synchronized breathing with movement control exercises protocol was feasible and may be more beneficial for improving multifactorial outcomes compared to identical exercises alone. Results suggested progression to a full-scale trial.

Protocol of identical exercise programs with and without specific breathing techniques for the treatment of chronic non-specific low back pain: randomized feasibility trial with two-month follow-up

BACKGROUND

Chronic low back pain (CLBP) is a leading cause of disability globally. Exercise therapies are one of the commonly prescribed treatment options for CLBP. The specific exercise therapies for CLBP most commonly target movement dysfunction, but seldom brain-based pain modulation. Exercise therapies with specific breathing techniques (SBTs) have been shown to influence and enhance brain-based structural and functional pain modulation.

AIMS AND OBJECTIVES

To assess the feasibility of the SBTs protocol, eligibility criteria, randomization, and dropout rates. To quantify the changes in patient outcome measures and choose the most relevant measure for larger-scale study. To quantify self-adherence levels to home exercise and monitor and record possible pain medication and other treatment modality usage, and adverse events during exercise.

DESIGN

A parallel randomised analyst-blinded feasibility trial with two-month follow-up.

OUTCOME MEASURES

Feasibility related to aims and objectives. Multiple pain- and health-related patient-reported outcome measures of pain intensity, disability, central sensitization, anxiety, kinesiophobia, catastrophising, self-efficacy, sleep quality, quality of life, and health and well-being status. Exercise adherence, pain medication and other treatment modality usage, and possible adverse events related to exercises will be monitored and recorded.

METHODS

Thirty participants will be randomized to movement control exercise with SBTs (15 subjects in experimental group) or movement control exercise without SBTs (15 subjects in control group) in private chiropractic practice setting with two-month follow-up. Trial registration number; NCT05268822.

DISCUSSION

The clinical difference in effectiveness between practically identical exercise programs in uniform study settings with or without SBTs has not been studied before. This study aims to inform feasibility and help determine whether progression to a full-scale trial is worthwhile.

The sensorimotor theory of pathological pain revisited

Harris (1999) proposed that pain can arise in the absence of tissue damage because changes in the cortical representation of the painful body part lead to incongruences between motor intention and sensory feedback. This idea, subsequently termed the sensorimotor theory of pain, has formed the basis for novel treatments for pathological pain. Here we review the evidence that people with pathological pain have changes to processes contributing to sensorimotor function: motor function, sensory feedback, cognitive representations of the body and its surrounding space, multisensory processing, and sensorimotor integration. Changes to sensorimotor processing are most evident in the form of motor deficits, sensory changes, and body representations distortions, and for Complex Regional Pain Syndrome (CRPS), fibromyalgia, and low back pain. Many sensorimotor changes are related to cortical processing, pain, and other clinical characteristics. However, there is very limited evidence that changes in sensorimotor processing actually lead to pain. We therefore propose that the theory is more appropriate for understanding why pain persists rather than how it arises.

Vitamin D inhibits TNF-α induced apoptosis of human nucleus pulposus cells through regulation of NF-kB signaling pathway

BACKGROUND

To observe the effects of vitamin D on the apoptotic human nucleus pulposus cells under tumor necrosis factor-α (TNF-α) treatment.

METHODS

The gene expression data was downloaded from the NCBI Gene Expression Omnibus (GEO) database ( https://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE34095 ). Differentially expressed genes between degenerative disc and non-degenerative disc were performed by R software. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genome (KEGG) pathway enrichment analyses were performed using The Database for Annotation, Visualization and Integrated Discovery (DAVID). Then, the human nucleus pulposus tissue was harvested from 12 patients according to the modified Pfirrmann classification and human nucleus pulposus cells were obtained from digestion of herniated nucleus pulposus tissue. The collected nucleus pulposus cells were treated with different concentration of TNF-α, and cellular apoptosis was measured by flow cytometry. Then, human nucleus pulposus cells were divided into following groups: normal culture medium, TNF-α treated, TNF-α, and vitamin D-treated groups. Cellular apoptosis rate was quantified by flow cytometry. Protein expression of p-p65, p65, and IkBa was detected with western blot analysis.

RESULTS

A total of 536 differentially expressed genes were identified through bioinformatic analysis. KEGG pathway revealed that NF-kB signaling pathway was involved in the process of disc degeneration. In the NP cell cultures, vitamin D significantly increased cell proliferation potency. Furthermore, vitamin D inhibited TNF-α induced apoptosis of human nucleus pulposus cells. Vitamin D reduced the phospho-NF-κB/p65 expression in the TNF-α-treated NP cells.

CONCLUSION

Vitamin D can attenuate TNF-α-induced NP cells apoptosis through interfering with the NF-κB pathway.