Effect of classification-specific treatment on lumbopelvic motion during hip rotation in people with low back pain

Increased and early lumbopelvic motion during trunk and limb movements is thought to contribute to low back pain (LBP). Therefore, reducing lumbopelvic motion could be an important component of physical therapy treatment. Our purpose was to examine the effects of classification-specific physical therapy treatment (Specific) based on the Movement System Impairment (MSI) model and non-specific treatment (Non-Specific) on lumbopelvic movement patterns during hip rotation in people with chronic LBP. We hypothesized that following treatment people in the Specific group would display decreased lumbopelvic rotation and achieve more hip rotation before lumbopelvic rotation began. We hypothesized that people in the Non-Specific group would display no change in these variables. Kinematic data collected before and after treatment for hip lateral and medial rotation in prone were analyzed. The Specific group (N = 16) demonstrated significantly decreased lumbopelvic rotation and achieved greater hip rotation before the onset of lumbopelvic rotation after treatment with both hip lateral and medial rotation. The Non-Specific group (N = 16) demonstrated significantly increased lumbopelvic rotation and no change in hip rotation achieved before the onset of lumbopelvic rotation. People who received treatment specific to their MSI LBP classification displayed decreased and later lumbopelvic motion with hip rotation, whereas people who received generalized non-specific treatment did not.     

Three-dimensional joint reaction forces and moments at the low back during over-ground walking in persons with unilateral lower-extremity amputation

Background

Abnormal mechanics of locomotion following lower-extremity amputation are associated with increases in trunk motion, which in turn may alter loads at the low back due to changes in inertial and gravitational demands on the spine and surrounding trunk musculature.

Methods

Over-ground gait data were retrospectively compiled from two groups walking at similar self-selected speeds (~ 1.35 m/s): 40 males with unilateral lower-extremity amputation (20 transtibial, 20 transfemoral) and 20 able-bodied male controls. Three-dimensional joint reaction forces and moments at the low back (L5/S1 spinal level) were calculated using top-down and bottom-up approaches. Peak values and the timings of these were determined and compared between and within (bilaterally) groups, and secondarily between approaches.

Findings

Peak laterally-directed joint reaction forces and lateral bend moments increased with increasing level of amputation, and were respectively 83% and 41% larger in prosthetic vs. intact stance among persons with transfemoral amputation. Peak anteriorly-directed reaction forces and extension moments were 31% and 55% larger, respectively, among persons with transtibial amputation compared to controls. Peak vertical reaction forces and axial twist moments were similar between and within groups. Peak joint reaction forces and moments were larger (3–14%), and the respective timing of these sooner (11–62 ms), from the bottom-up vs. top-down approach.

Interpretation

Increased and asymmetric peak reaction forces and moments at the low back among persons with unilateral lower-extremity amputation, particularly in the frontal plane, suggest potential mechanistic pathways through which repeated exposure to altered trunk motion and spinal loading may contribute to low-back injury risk among persons with lower-extremity amputation.     

Sex differences in lumbopelvic movement patterns during hip medial rotation in people with chronic low back pain

Hoffman SL, Johnson MB, Zou D, Van Dillen LR. Sex differences in lumbopelvic movement patterns during hip medial rotation in people with chronic low back pain.

Objective

To examine sex differences in lumbopelvic motion and symptom behavior during hip medial rotation in people with low back pain (LBP). We hypothesized that men would demonstrate greater and earlier lumbopelvic motion and would be more likely to report increased symptoms compared with women.

Design

Cross-sectional observational study.

Setting

University musculoskeletal analysis laboratory.

Participants

Persons with chronic LBP (N=59; 30 men, 29 women) were recruited from the community and a university-based physical therapy clinic.

Interventions

Not applicable.

Main Outcome Measures

Lumbopelvic rotation range of motion, amount of hip rotation completed before the start of lumbopelvic motion, and provocation of LBP symptoms during the test of prone hip medial rotation were measured.

Results

Men demonstrated significantly more lumbopelvic rotation (men, 10.0°±5.1°; women, 4.5°±3.9°; P<.001) and completed less hip rotation before the start of lumbopelvic motion (men, 5.4°±3.8°; women, 16.0°±13.2°; P<.001) compared with women. Additionally, a significantly greater percentage of men (60.0%) than women (34.5%; P=.050) reported increased symptoms with hip medial rotation.

Conclusions

Men could be at greater risk than women for experiencing LBP symptoms related to hip medial rotation as a result of greater and earlier lumbopelvic motion.     

Redistribution of joint moments during walking in patients with drop-foot

Background

The purpose of the study was to analyze the distribution of net joint moments in the lower extremities in patients walking with a drop-foot compared to a group of healthy subjects. A drop-foot causes the patient to walk with a characteristic limp and it was hypothesized that the drop-foot could lead to increased loadings of one or more joints.

Methods

Six patients and fourteen healthy subjects walked at a fixed speed over two recessed force platforms while the movements were recorded by six infrared cameras. Net joint moments were calculated by inverse dynamics.

Findings

The patients showed an almost doubled peak knee extensor moment during the stance phase compared to healthy subjects. This was accompanied by an increased knee joint flexion. The increased extensor moment about the knee joint was found in both the affected and unaffected leg of the patients. This was accompanied by increased maximal knee joint flexion in both legs of the patients compared to the healthy subjects. Several additional differences were observed in joint moments and joint angles between the two groups and between the two legs of the patients.

Interpretation

The increased knee joint extensor moment leads to increased joint loading, which potentially may lead to development of osteo-arthritis over the years. It is recommended that patients with a drop-foot are offered an ankle joint orthosis in an attempt to restore normal function of the ankle joint, which will most likely reduce the knee joint loadings.     

Gender differences in pattern of hip and lumbopelvic rotation in people with low back pain

BACKGROUND: Findings from previous studies suggest gender may affect the pattern of hip and lumbopelvic motion during a multi-segmental movement. To date, no studies have examined movement patterns and low back pain symptom behavior during hip lateral rotation. METHODS: Forty-six people (27 males and 19 females) with low back pain were examined. Three-dimensional kinematic data and low back pain symptoms were recorded during active hip lateral rotation. Percent of maximum lumbopelvic rotation was calculated for each 10% increment of maximum active hip lateral rotation. FINDINGS: Men exhibited a greater percent of maximum lumbopelvic rotation (mean 49.3, SD 13.3) during the first 60% of hip lateral rotation than women (mean 36.2, SD 16.4) (P < 0.01). Nineteen (70.4%) of the men and seven (36.8%) of the women had pain with the hip lateral rotation test (P = 0.02). INTERPRETATION: Men exhibited more lumbopelvic rotation in the early part of hip lateral rotation than women, and hip lateral rotation was more likely to be associated with symptoms in men than women. Greater lumbopelvic motion, earlier in hip lateral rotation, may make men more vulnerable to low back pain associated with hip lateral rotation. Factors that contribute to these gender differences should be investigated further.     

Predictors of walking performance and walking capacity in people with lumbar spinal stenosis, low back pain, and asymptomatic controls

Tomkins-Lane CC, Holz SC, Yamakawa KS, Phalke VV, Quint DJ, Miner J, Haig AJ. Predictors of walking performance and walking capacity in people with lumbar spinal stenosis, low back pain, and asymptomatic controls.ObjectiveTo examine predictors of community walking performance and walking capacity in people with lumbar spinal stenosis (LSS), compared with people with low back pain and asymptomatic control subjects.DesignRetrospective analysis.SettingUniversity spine program.ParticipantsParticipants (N=126; 50 LSS, 44 low back pain, 32 asymptomatic control subjects) aged 55 to 80 years were studied.InterventionsNot applicable.Main Outcome MeasuresSeven-day community walking distance measured by pedometer (walking performance) and a 15-minute walking test (walking capacity). All participants had lumbosacral magnetic resonance imaging, electrodiagnostic testing, and a history and physical examination, including a history of pain and neurologic symptoms, a straight leg raise test, and tests for directional symptoms, reflexes, strength, and nerve tension signs. The study questionnaire included demographic information, a history of back/leg pain, and questions about walking, exercise frequency, and pain level, as well as the standardized Quebec Back Pain Disability Scale.ResultsBody mass index (BMI), pain, age, and female sex predicted walking performance (r²=.41) and walking capacity (r²=.41). The diagnosis of LSS itself had no clear relationship with either walking variable. Compared with the asymptomatic group, LSS participants had significantly lower values for all walking parameters, with the exception of stride length, while there was no significant difference between the LSS and low back pain groups.ConclusionsBMI, pain, female sex, and age predict walking performance and capacity in people with LSS, those with low back pain, and asymptomatic control subjects. While pain was the strongest predictor of walking capacity, BMI was the strongest predictor of walking performance. Average pain, rather than leg pain, was predictive of walking performance and capacity. Obesity and pain are modifiable predictors of walking deficits that could be targets for future intervention studies aimed at increasing walking performance and capacity in both the low back pain and LSS populations.     

青年慢性下腰痛患者腰背肌耐力比较研究

目的 :研究青年下腰痛患者腰背肌耐力的变化。方法 :应用CYBEX - 6 0 0 0型等速测试训练系统和肌电图测试腰痛组 (n =4 0 )和正常组 (n =4 0 )的腰背肌耐力指标 ,进行两组间比较。结果 :腰痛组腰背肌耐力比与正常组无差异 (P >0 .0 5 ) ;腰痛组腰背肌肌电图波幅低于正常组 (P <0 .0 5 )、时程大于正常组 (P <0 .0 5 ) ,腰痛组腰背肌肌电图波幅随时间衰减程度大于正常组 (P <0 .0 5 )、时程随时间延长程度大于正常组 (P <0 .0 5 )。结论 :青年下腰痛患者存在着明显的腰背肌静态耐力下降 ,腰背肌耐力比与下腰痛关系并不密切。     

Disorders in trunk rotation during walking in patients with low back pain: a dynamical systems approach

OBJECTIVE: (1) To introduce an evaluation tool for the assessment of walking disorders in low back pain patients. (2) To investigate whether walking patterns in low back pain patients are different from those of control subjects. DESIGN: Relative phase measures of movement coordination are applied in the assessment of trunk function in a small group of patients with non-specific low back pain and in control subjects. BACKGROUND: Normal subjects change the coordination of pelvic and thoracic rotations from an in-phase to an out-of-phase pattern with increasing walking speed. Low back pain patients may have a reduced ability to counter rotate pelvis and thorax at higher walking speeds (from 1.0 m/s onwards) as a result of hyperstable coordination patterns. METHODS: Six patients with non-specific low back pain and six healthy control subjects walked on a treadmill at comfortable walking speeds and during a systematic variation of the treadmill velocity. Coordination of arm and leg movements as well as of pelvic and thoracic rotations was analyzed using a relative phase algorithm. RESULTS AND CONCLUSIONS: The comfortable walking speed was reduced in the patient group. In contrast to the control subjects, four of the six patients were not able to establish an out-of-phase coordination pattern between thorax and pelvis at higher walking speeds. This coincided with an increased stability of movement coordination, indicating guarded behavior. In addition, an increased asymmetry between the phase-relations of left and right side of the body was found in some of the patients.     

Symmetry of timing of hip and lumbopelvic rotation motion in 2 different subgroups of people with low back pain

OBJECTIVES: To examine whether lumbopelvic motion associated with a clinical test of active hip lateral rotation (HLR) systematically varied between people classified into 1 of 2 low back pain (LBP) subgroups: lumbar rotation (Rot) or lumbar rotation with extension (RotExt); and, specifically, to determine whether the timing of hip and lumbopelvic rotation with HLR would be more symmetric, right versus left, in people in the Rot subgroup compared with the RotExt subgroup. DESIGN: Two-group, cross-sectional. SETTING: A university-based movement science laboratory. PARTICIPANTS: Subjects were 39 people (23 men, 16 women; mean age, 28.1+/-8.0 y) with chronic or recurrent LBP who regularly participated in a rotation-related sport and associated their LBP symptoms with participation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Subjects participated in a standardized clinical examination to classify their LBP problem. A 3-dimensional movement system was used to capture kinematics of hip and lumbopelvic rotation during the test of active HLR. To examine timing of motion between the hip and lumbopelvic region, the difference in time between the start of hip and lumbopelvic rotation was calculated (startdiff). Symmetry of motion was indexed by the correlation (r) between right and left startdiff and the coefficient of determination (r2) for each LBP subgroup. RESULTS: There were no significant differences between the 2 groups with regard to subject, LBP, activity, and range of motion variables (P range, >.05 for all comparisons). People in the Rot subgroup displayed significantly more symmetry of timing of hip and lumbopelvic rotation motion with active HLR than people in the RotExt subgroup (Rot subgroup: r=.94, r2=.88, P=.00; RotExt subgroup: r=.31, r2=.10, P=.12). CONCLUSIONS: People in the Rot and RotExt subgroups displayed systematic differences in how they moved the hip and lumbopelvic region with the clinical test of active HLR. These findings are potentially important because such differences in movement patterns between subgroups of people with LBP suggest different contributing factors and may require different treatments to affect the movement patterns.     

Factors contributing to lumbar region passive tissue characteristics in people with and people without low back pain

Background

Previously, we demonstrated that people in the Rotation with Extension low back pain subgroup display greater asymmetry of passive tissue characteristics during trunk lateral bending than people without low back pain. The purpose of this secondary analysis is to examine factors that explain the group differences.

Methods

Twenty-two people in the Rotation with Extension subgroup, and 19 people without low back pain were examined. Torque, lumbar region kinematics, and trunk muscle activity were measured during passive and isometric resisted trunk lateral bending. The dependent variables were lumbar region passive elastic energy to each side; the independent variables included group, gender, anthropometrics, trunk muscle characteristics, and an interaction factor of group and trunk muscle characteristics. Multiple linear regression was used for the analysis.

Findings

Anthropometrics explained passive measures to the left (P = .03). Anthropometrics (P < .01), trunk muscle characteristics (P < .01), and the interaction of group and trunk muscle characteristics (P = .01) explained passive measures to the right. After accounting for gender and anthropometrics, 43.7% of the variance in passive measures to the right was uniquely accounted for by trunk muscle characteristics for the Rotation with Extension subgroup, compared to 0.5% for the group without low back pain.

Interpretation

Anthropometrics explained passive measures with trunk lateral bending to both sides, in both groups. For people in the Rotation with Extension subgroup, there was a direct relationship between trunk muscle performance and passive measures to the right. Muscle is an important contributing factor to asymmetry in this subgroup and should be considered in treatment.     

Differences in lumbopelvic motion between people with and people without low back pain during two lower limb movement tests

Background

Clinical data suggest that active limb movements may be associated with early lumbopelvic motion and increased symptoms in people with low back pain.

Methods

Forty-one people without low back pain who did not play rotation-related sports and 50 people with low back pain who played rotation-related sports were examined. Angular measures of limb movement and lumbopelvic motion were calculated across time during active knee flexion and active hip lateral rotation in prone using a three-dimensional motion capture system. Timing of lumbopelvic motion during the limb movement tests was calculated as the difference in time between the initiation of limb movement and lumbopelvic motion normalized to limb movement time.

Findings

During knee flexion and hip lateral rotation, people with low back pain demonstrated a greater maximal lumbopelvic rotation angle and earlier lumbopelvic rotation, compared to people without low back pain (P < 0.05).

Interpretation

The data suggest that people with low back pain who play rotation-related sports may move their lumbopelvic region to a greater extent and earlier during lower limb movements than people without low back pain. Because people perform many of their daily activities in early to midranges of joint motion the lumbopelvic region may move more frequently across the day in people with low back pain. The increased frequency may contribute to increased lumbar region tissue stress and potentially low back pain symptoms. Lower limb movements, therefore, may be important factors related to the development or persistence of low back pain.     

Forces applied during manual therapy to patients with low back pain

BACKGROUND: To date, there is little information available regarding the forces used during mobilization treatment of patients with low back pain (LBP). OBJECTIVE: This study measured such forces and investigated whether the force characteristics could be predicted on the basis of physical therapist and patient characteristics. SUBJECTS: Ten physical therapists applied a central posteroanterior (PA) mobilization treatment to 80 patients with LBP, providing data on treatment of 123 lumbar levels. METHODS: Physical therapists were required to treat their patients while the patients lay on an instrumented couch. This couch has been shown to be highly accurate in its measurement of force in 3 directions (error <2%) and has demonstrated high test-retest reliability (ICC [2, 1], 99% CI = 0.99-1.00). The forces applied by the physical therapists were recorded over a 10-second period. Data on the characteristics of the physical therapists and patients were collected by means of questionnaires. RESULTS: The force used by physical therapists related not only to patient characteristics but also to physical therapist characteristics. Interestingly, current pain intensity and nature of symptoms did not affect the forces used. The overall patterns of the force characteristics were generally consistent with previous studies performed in asymptomatic subjects. However, the magnitude of the force applied and the frequency of each grade used in the present study are relatively higher than in earlier studies. CONCLUSION: These preliminary data provide some useful quantitative information about the forces used during mobilization treatment of patients with LBP. Also, the force characteristics described here may provide useful data for both teaching and research in manual therapy.     

The immediate effects of neuromuscular joint facilitation on chronic low back pain in young and elderly people

[Purpose] This study aimed to investigate the changes in the pain severity and muscle hardness of the multifidus and longissimus muscles of young and elderly patients with low back pain after neuromuscular joint facilitation treatment. [Participants and Methods] The participants were 13 young patients and 11 elderly patients with chronic low back pain. The neuromuscular joint facilitation lumbar approach was used in all participants. The muscle hardness of the multifidus and longissimus muscles was assessed at the L4 and L5 levels of the lumbar spine. The changes in pain severity of low back pain were assessed using a visual analogue scale before and after treatment. [Results] Visual analogue scale scores significantly decreased in both groups after treatment. The young group showed significant differences in muscle hardness pre- and post-intervention. In addition, except for the muscle hardness of the multifidus muscle before intervention, on the side with pain at the L5 level, longissimus muscle hardness was higher in the elderly, as compared to the young patient group. [Conclusion] Interventions with neuromuscular joint facilitation have an immediate effect on pain relief in young and elderly people with chronic low back pain and on muscle spasms in young people with chronic low back pain.     

Movement variability in adults with low back pain during sit-to-stand-to-sit

BackgroundDifferences in movement variability may be related to a guarded response to pain or a less robust movement pattern, indicating a potential dysfunction in motor control. The study objective was to compare patterns of lumbo-pelvic coordinative variability, during repeated sit-to-stand-to-sit, in individuals with low back pain and healthy adults.MethodsParticipants were adults with low back pain (n = 16) and healthy controls (n = 21). Kinematics for the T12-L3, L3-S1, and hip segments were measured using electromagnetic motion capture during 10 sit-to-stand-to-sit trials. Continuous relative phase analysis using the Hilbert transform method determined coordination and variability of the Hip-L3S1, and L3S1-T12L3 segments, deconstructed into 4 periods (start/up/down/end). T-tests compared coordination and variability of the full task between groups, and a mixed ANOVA compared the effects of group and period for the two segments.FindingsAcross the full task, the low back pain group demonstrated more variable (mean difference = −6.95, 95% CI = −12.3 to −1.59) and greater out-of-phase behavior (mean difference = −22.6, 95% CI = −39.1 to −6.03) in the LHip-L3S1 segment. Group-period interaction effects revealed greater variability in the start period (mean difference = −0.325, 95% CI = −0.493 to −0.156) and more out-of-phase behavior in the start (mean difference = −0.350, 95% CI = −0.549 to −0.150) and end (mean difference = −0.354, 95% CI = −0.602 to −0.105) periods for the LHip-L3S1 segment.InterpretationExcessive variability may relate to reports of poor spinal proprioception in low back pain; however, based on our sample characteristics (low pain and disability) and lack of symptoms during the task, classifying our findings as dysfunctional may not be fully warranted.     

Effect of the walking speed to the lower limb joint angular displacements, joint moments and ground reaction forces during walking in water

Purpose: The purpose of this study was to compare the changes in ground reaction forces (GRF), joint angular displacements (JAD), joint moments (JM) and electromyographic (EMG) activities that occur during walking at various speeds in water and on land.

Method: Fifteen healthy adults participated in this study. In the water experiments, the water depth was adjusted so that body weight was reduced by 80%. A video-motion analysis system and waterproof force platform was used to obtain kinematics and kinetics data and to calculate the JMs.

Results: Results revealed that (1) the anterior-posterior GRF patterns differed between walking in water and walking on land, whereas the medio-lateral GRF patterns were similar, (2) the JAD patterns of the hip and ankle were similar between water- and land-walking, whereas the range of motion at the knee joint was lower in water than on land, (3) the JMs in all three joints were lower in water than on land throughout the stance phase, and (4) the hip joint extension moment and hip extensor muscle EMG activity were increased as walking speed increase during walking in water.

Conclusions: Rehabilitative water-walking exercise could be designed to incorporate large-muscle activities, especially of the lower-limb extensor muscles, through full joint range of motion and minimization of joint moments.