Hip-focused physical therapy versus spine-focused physical therapy for older adults with chronic low back pain at risk for mobility decline (MASH): a multicentre, single-masked, randomised controlled trial.

BACKGROUND: Previously, we identified a population of older adults with chronic low back pain, hip pain, and hip muscle weakness who had worse 12-month low back pain and functional outcomes than age-matched adults with only low back pain, indicating an increased risk for future mobility decline. We sought to determine whether tailored, hip-focused physical therapy reduced pain and functional limitations in this high-risk population compared with non-tailored, spine-focused physical therapy. METHODS: We did a multicentre, single-masked, randomised controlled trial at three research-based sites in the USA. We recruited older adults (aged 60-85 years) with hip pain and weakness who reported moderate low back pain intensity at least half the days in the last 6 months. Patients were randomly assigned to hip-focused physical therapy or spine-focused physical therapy using permuted blocks with random block size, stratified by site and sex (ie, male or female). The primary outcomes were self-reported disability using the Quebec Back Pain Disability Scale (QBPDS) and performance-based 10-Meter Walk Test (10MWT) at 8 weeks. All analyses were done in the intention-to-treat population. Adverse events were collected by study staff via a possible adverse event reporting form and then adjudicated by site investigators. This trial was registered with ClinicalTrials.gov, NCT04009837. FINDINGS: Between Nov 1, 2019, and April 30, 2022, 184 participants were randomly assigned to receive hip-focused (n=91) or spine-focused physical therapy (n=93) interventions. The mean age was 70·7 (SD 6·2) years. 121 (66%) of 184 participants were women, 63 (34%) were men, and 149 (81%) were White. At 8 weeks, the mean between-group difference on the QBPDS was 4·0 (95% CI 0·5 to 7·5), favouring hip-focused physical therapy. Both groups had similar, clinically meaningful gait speed improvements (10MWT) at 8 weeks (mean difference 0·004 m/s [95% CI -0·044 to 0·052]). No serious adverse events were related to study participation. INTERPRETATION: Tailored hip-focused physical therapy demonstrated greater improvements in low back pain-related disability at 8 weeks. However, both hip-focused physical therapy and spine-focused physical therapy produced clinically meaningful improvements in disability and function for this high-risk population at 6 months. These findings warrant further investigation before clinical implementation. FUNDING: US National Institute on Aging of the National Institutes of Health.

Trajectories of Physical Function and Disability Over 12 Months in Older Adults With Chronic Low Back Pain.

BACKGROUND AND PURPOSE: Understanding prognosis is critical for clinical care and health policy initiatives. The purpose of this study was to determine whether distinct prognostic trajectories of physical function and disability exist in a cohort of 245 community-dwelling older adults with chronic low back pain (LBP), and to characterize the demographic, health, and pain-related profiles of each trajectory subgroup. METHODS: All participants underwent standard clinic examinations at baseline, 3 months, 6 months, and 12 months. At each time point, the Late Life Function & Disability Instrument (LLFDI) was used to measure general physical function (LLFDI Function) and disability (LLFDI Disability-Limitation); the Quebec LBP Disability Questionnaire was used to measure disability due to pain. Growth mixture modeling (GMM) was performed on each outcome to identify distinct trajectory classes/subgroups; baseline demographic (eg, age and sex), health (eg, comorbidities, depressive symptoms, and physical activity level), and pain-related (eg, LBP intensity, pain-related fear, and pain catastrophizing) characteristic profiles were compared across subgroups. RESULTS: GMM statistics revealed an optimal number of 3 to 4 trajectory subgroups, depending on the outcome examined. Subgroups differed across demographic, health, and pain-related characteristics; the classes with the most favorable prognoses had consistent profile patterns: fewer depressive symptoms, fewer comorbidities, higher physical activity levels, lower LBP intensities, less pain-related fear, and less pain catastrophizing. CONCLUSION: Our findings indicate that several distinct trajectory subgroups exist that would have been masked by observing mean cohort change alone. Furthermore, subgroup characteristic profiles may help clinicians identify likely prognostic trajectories for their patients. Future research should focus on identifying modifiable risk factors that best predict group membership, and tailoring interventions to mitigate the risk of poor prognosis.

The Manual Therapy and Strengthening for the Hip (MASH) Trial: Protocol for a Multisite Randomized Trial of a Subgroup of Older Adults With Chronic Back and Hip Pain.

OBJECTIVE: Chronic low back pain (CLBP) is a disabling and costly condition for older adults that is difficult to properly classify and treat. In a cohort study, a subgroup of older adults with CLBP who had elevated hip pain and hip muscle weakness was identified; this subgroup differentiated itself by being at higher risk for future mobility decline. The primary purpose of this clinical trial is to evaluate whether a hip-focused low back pain (LBP) treatment provides better disability and physical performance outcomes for this at-risk group compared with a spine-focused LBP treatment. METHODS: This study is a multisite, single-blinded, randomized controlled, parallel arm, Phase II trial conducted across 3 clinical research sites. A total of 180 people aged between 60 and 85 years with CLBP and hip pain are being recruited. Participants undergo a comprehensive baseline assessment and are randomized into 1 of 2 intervention arms: hip-focused or spine-focused. They are treated twice weekly by a licensed physical therapist for 8 weeks and undergo follow-up assessments at 8 weeks and 6 months after randomization. Primary outcome measures include the Quebec Low Back Disability Scale and the 10-Meter Walk Test, which are measures of self-report and performance-based physical function, respectively. IMPACT: This multicenter, randomized clinical trial will determine whether a hip-focused or spine-focused physical therapist intervention results in improved disability and physical performance for a subgroup of older adults with CLBP and hip pain who are at increased risk of mobility decline. This trial will help further the development of effective interventions for this subgroup of older adults with CLBP.

Classification of Geriatric Low Back Pain Based on Hip Characteristics With a 12-Month Longitudinal Exploration of Clinical Outcomes: Findings From Delaware Spine Studies.

OBJECTIVE: The purpose of this study is to identify geriatric chronic low back pain (LBP) subgroups based on the presence of potentially modifiable hip impairments, using Latent Variable Mixture Modeling (LVMM), and to examine the prospective relationship between these subgroups and key outcomes over time. METHODS: Baseline, 3-month, 6-month, and 12-month data were collected from a prospective cohort of 250 community-dwelling older adults with chronic LBP. Comprehensive hip (symptoms, strength, range of motion, and flexibility), LBP (intensity and disability), and mobility function (gait speed and 6-Minute Walk Test) examinations were performed at each timepoint. Baseline hip measures were included in LVMM; observed classes/subgroups were compared longitudinally on LBP and mobility function outcomes using mixed models. RESULTS: Regarding LVMM, a model with 3 classes/subgroup fit best. Broadly speaking, subgroups were differentiated best by hip strength and symptom presence: subgroup 1 = strong and nonsymptomatic, subgroup 2 = weak and nonsymptomatic, and subgroup 3 = weak and symptomatic (WS). Regarding longitudinal mixed models, all subgroups improved in most outcomes over time. Specifically, over 12 months, the nonsymptomatic subgroups had lower LBP intensity and disability levels compared with the WS subgroup, whereas the strong and nonsymptomatic subgroup had better mobility function than the 2 "weak" subgroups. CONCLUSION: These subgroup classifications may help in tailoring specific interventions in future trials. Special attention should be given to the WS subgroup given their consistently poor LBP and mobility function outcomes. IMPACT: Among older adults with chronic low back pain, there are 3 hip subgroups: "strong and nonsymptomatic," "weak and nonsymptomatic," and "weak and symptomatic." People in these subgroups demonstrate different outcomes and require different treatment; proper identification will result in tailored interventions designed to benefit individual patients. In particular, people in the WS subgroup deserve special attention, because their outcomes are consistently poorer than those in the other subgroups.

Hip Range of Motion and Strength Predict 12-Month Physical Function Outcomes in Older Adults With Chronic Low Back Pain: The Delaware Spine Studies.

OBJECTIVE: The objective of this study was to investigate whether poor hip range of motion (ROM) and strength predict 12-month physical function decline among older adults with chronic low back pain (LBP) and whether hip osteoarthritis modifies those relationships. METHODS: At baseline, passive ROM and strength measurements were taken for hip flexion, extension, abduction, adduction, internal rotation, and external rotation; ultrasound images and self-reported symptoms were used to evaluate hip osteoarthritis presence (eg, osteophytes and hip pain). At baseline and 12 months, performance-based (repeated chair rise, self-selected gait speed, 6-minute walk test [6MWT]) and self-reported (Quebec LBP Disability Questionnaire, Late-Life Function & Disability Instrument [LLFDI] basic and advanced lower extremity scales) physical function outcomes were assessed. Regression models were constructed for each outcome predicted by baseline hip ROM and strength measures, with adjustment for potential covariates. To avoid collinearity, hip ROM and strength measures with the strongest unadjusted correlations were included in final models. The hip osteoarthritis presence by hip ROM/strength interaction was also explored. RESULTS: Hip abduction strength predicted repeated chair rise (ß = -0.297, P < 0.001), gait speed (ß = 0.160, P = 0.003), 6MWT (ß = 0.159, P ≤ 0.001), Quebec LBP Disability Questionnaire (ß = -0.152, P = 0.003), and LLFDI basic lower extremity scale (ß = 0.171, P = 0.005) outcomes. Regarding hip ROM, extension predicted repeated chair rise (ß = -0.110, P = 0.043) and LLFDI advanced lower extremity scale (ß = 0.090, P = 0.007) outcomes, external rotation predicted gait speed (ß = 0.122, P = 0.004) outcomes, and abduction predicted LLFDI basic lower extremity scale (ß = 0.114, P = 0.026) outcomes. The hip osteoarthritis interaction was not significant for any model. CONCLUSION: Reduced hip strength and ROM predict physical function decline; hip osteoarthritis presence may not modify these relationships.

Pain Provocation and the Energy Cost of Walking: A Matched Comparison Study of Older Adults With and Without Chronic Low Back Pain With Radiculopathy.

BACKGROUND AND PURPOSE: Chronic low back pain with radiculopathy (CLBPR) is common among older adults and can lead to walking difficulty. Energy cost of walking strongly predicts changes in walking speed, which is predictive of mortality in older adults. The purposes of this study were to examine (1) the impact of pain provocation on the energy cost of walking and (2) the relationship between pain intensity and change in energy cost of walking. METHODS: Older adults (60-85 years) with (n = 20) and without (n = 20) CLBPR were matched on age, sex, and diabetes presence/absence. Energy cost of walking was measured with a portable metabolic gas analyzer, as participants walked for 20 minutes or less. Energy cost and pain measurements occurred during early and late stages of walking. Percent change in energy cost was calculated. Participants were grouped by their pain response during walking: increased pain (n = 13); consistent pain (n = 7); no pain, matched to individuals with increased pain (n = 13); and no pain, matched to individuals with consistent pain (n = 7). We examined the within-groups change in energy cost for all groups, as well as the relationship between late-stage pain intensity and percent change of energy cost for individuals whose pain increased. RESULTS AND DISCUSSION: Within the increased pain group, energy cost of walking significantly increased from early to late stages (median change = 0.003 mL/kg/m, P = .006), and late-stage pain intensity explained 41.2% (p = 0.040) of the variance in percent change. Since pain appears to be linked to energy cost, effective pain management with walking may be an important factor in preventing mobility decline. CONCLUSIONS: Among older adults with CLBPR, pain provocation drives increases in the energy cost of walking. Because high energy cost of walking is predictive of mobility decline, clinicians may focus on effective pain management strategies during walking, which may potentially decrease the risk of mobility decline.

Use of trunk muscle training and neuromuscular electrical stimulation to reduce pain and disability in an older adult with chronic low back pain: A case report.

Among older adults, low back pain (LBP) is common, costly, and disabling. Trunk muscle training (TMT) and neuromuscular electrical stimulation (NMES) have both been found to be effective in reducing LBP, but studies among older adults have been limited. An 83-year-old female with left-sided chronic LBP participated in a randomized controlled trial consisting of supervised TMT and NMES to the paraspinal muscles two times per week for 12 weeks. She also participated in a home exercise program. At the end of the intervention, she reported reduced LBP and LBP-related disability per the modified Oswestry disability index (i.e., 60% at baseline to 40% at 12 weeks). Her Short Physical Performance Battery summary score improved from 4/12 at baseline to 10/12 at 12 weeks, while her Timed Up and Go test improved from 17.21 to 15.20 s and her Repetitive Trunk Rotation test from 2.72 to 1.93 s/right-left rotation. This case demonstrates a positive short-term treatment response to TMT supplemented with NMES of the paraspinal muscles in an older adult with chronic LBP. A packaged intervention of TMT plus NMES may be a means of addressing not only LBP, but also impaired physical function and resultant disability.

Test-Retest Reliability of Dynamic Balance Performance-Based Measures Among Adults With a Unilateral Lower-Limb Amputation.

BACKGROUND: There is large variation in administration of performance-based, dynamic balance measures among adults with lower-limb amputation (LLA). Further, there has been limited exploration of test-retest reliability of these measures in adults with lower-limb loss, including whether there is a difference in reliability if one records "best" vs "average" performance across trials. OBJECTIVE: To determine test-retest reliability of several balance tests for both "best" and "average" score performance in community-dwelling adults with a unilateral LLA, including quantification of the precision of individual scores (SE of the measurement, SEM) and estimates of minimal detectable change (MDC90 ). DESIGN: Cross-sectional study. SETTING: Mobile research laboratory. PARTICIPANTS: 27 participants (55.5% female) with an average age of 51 (SD = 12.2) years, who were predominantly community-ambulators (92.5%), after a unilateral transtibial (n = 20), transfemoral (n = 5), or other major lower-extremity (n = 2) amputation, were included. Median time since amputation was 6.3 (2.3, 19 [25th, 75th interquartile range]) years. METHODS: Reliability was evaluated using intraclass correlation coefficient (ICC) models (3,1 or 3,k). SEMs and MDC90 values with 95% confidence intervals (CIs) were calculated. MAIN OUTCOME MEASURES: 360o Turn Test, 5 Times Sit-To-Stand, Functional Reach Test, Figure-of-8 Walk Test, and Four Square Step Test (FSST). RESULTS: The ICCs (3,1 or 3,k) for all tests (for both "best" and "average" performance) were considered good-to-excellent and CIs varied from 0.69 (95% CI = 0.40-0.85) to 0.97 (95% CI = 0.95-0.99). For most tests, "best" and "average" performance demonstrated similar ICC values. MDC90 values did not surpass 10% of test means for any of the measures. CONCLUSIONS: The dynamic balance measures evaluated for use among community-dwelling adults with a unilateral LLA demonstrated excellent reliability, along with high precision of scores and MDC values that did not exceed 10% of testing means. Either best or average scoring may be used when administering the majority of these tests, as long as the assessment method is appropriately documented and replicated at follow-up to allow direct comparisons. With the FSST, clinicians should consider taking the average of two FSST trials. LEVEL OF EVIDENCE: III.

Energy Impairments in Older Adults With Low Back Pain and Radiculopathy: A Matched Case-Control Study.

OBJECTIVES: To investigate the impact that the presence of chronic low back pain with radiculopathy (CLBPR) may have on (1) energy efficiency and (2) energy capacity among community-dwelling older adults. DESIGN: Matched case-control study. SETTING: Clinical research laboratory. PARTICIPANTS: Included in the analysis were community-dwelling older adults (N=38, 60-85 years) with and without CLBPR. Participants were matched between-groups on age (±5 years), sex, and diabetic status. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Energy cost of walking at self-selected speed (ie, energy efficiency) and peak volume of oxygen consumed (ie, energy capacity). RESULTS: Older adults with CLBPR had a higher energy cost of walking at self-selected speed (P=.009) and lower peak volume of oxygen consumed while walking (P=.050), compared to those without pain. CONCLUSIONS: Older adults with CLBPR may benefit from specific rehabilitative interventions that target these potentially modifiable energetic outcomes, thereby reducing the risk of mobility decline. Future studies should identify which mechanisms specifically contribute to diminished energy efficiency and capacity among older adults with CLBPR.

Hip Symptoms, Physical Performance, and Health Status in Older Adults With Chronic Low Back Pain: A Preliminary Investigation.

OBJECTIVES: To determine (1) whether there are differences in the prevalence of clinical hip symptoms between older adults with and without chronic low back pain (CLBP); and (2) whether coexisting hip symptoms are associated with worse physical performance and poorer health-related quality of life (HRQOL). DESIGN: Case-control study. SETTING: Individuals participated in a standardized evaluation in a clinical laboratory. PARTICIPANTS: Clinical hip symptoms, which are proposed predictors of radiographic hip osteoarthritis according to American College of Rheumatology guidelines, were evaluated in a volunteer sample of community-dwelling older adults with CLBP (n=54; aged 60-85y) and in age- and sex-matched healthy controls (n=54). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Physical performance was measured by the repeated chair rise test and stair-climbing test. HRQOL was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). RESULTS: Hip joint pain, morning stiffness, and pain with hip internal rotation were more common among older adults with CLBP (P<.05). Participants with CLBP and coexisting hip symptoms had worse physical performance than individuals without CLBP or hip symptoms (P<.0001). Additionally, the presence of coexisting hip symptoms was associated with worse HRQOL, particularly in the domains of social functioning, mental health, and role limitations attributable to emotional problems as measured by the SF-36 (P<.01). CONCLUSIONS: Given our limited understanding of CLBP among older adults, there is a definitive need to systematically explore coexisting pain conditions that may contribute to worse outcomes. Based on these data, future longitudinal studies should explore whether coexisting hip symptoms are associated with a worse prognosis in older adults with CLBP.

Altered spatiotemporal characteristics of gait in older adults with chronic low back pain.

Previous studies in older adults have identified that chronic low back pain (CLBP) is associated with slower gait speed. Given that slower gait speed is a predictor of greater morbidity and mortality among older adults, it is important to understand the underlying spatiotemporal characteristics of gait among older adults with CLBP. The purposes of this study were to determine (1) if there are differences in spatiotemporal parameters of gait between older adults with and without CLBP during self-selected and fast walking and (2) whether any of these gait characteristics are correlated with performance of a challenging walking task, e.g. stair negotiation. Spatiotemporal characteristics of gait were evaluated using a computerized walkway in 54 community-dwelling older adults with CLBP and 54 age- and sex-matched healthy controls. Older adults with CLBP walked slower than their pain-free peers during self-selected and fast walking. After controlling for body mass index and gait speed, step width was significantly greater in the CLBP group during the fast walking condition. Within the CLBP group, step width and double limb support time are significantly correlated with stair ascent/descent times. From a clinical perspective, these gait characteristics, which may be indicative of balance performance, may need to be addressed to improve overall gait speed, as well as stair-climbing performance. Future longitudinal studies confirming our findings are needed, as well as investigations focused on developing interventions to improve gait speed and decrease subsequent risk of mobility decline.

Trunk Muscle Characteristics of the Multifidi, Erector Spinae, Psoas, and Quadratus Lumborum in Older Adults With and Without Chronic Low Back Pain.

Study Design Cross-sectional study. Objective To determine whether there are differences in trunk muscle characteristics between older adults with and without chronic low back pain (LBP), while controlling for age, sex, and body mass index. Background Muscle support for the trunk is provided by the multifidi, erector spinae, psoas, and quadratus lumborum. Trunk muscle characteristics may be altered with aging and/or chronic LBP. To date, most trunk muscle research has been conducted among younger adults. Given age-related muscle changes, such as reduced size and increased intramuscular fat, studies are needed in older adults, including those comparing older adults with and without LBP. Methods One hundred two older adults with (n = 53) and without (n = 49) chronic LBP were included. Cross-sectional area (CSA) measurements were taken by tracing inside the fascial borders on magnetic resonance images. Pixel intensity summaries were obtained to compute muscle-to-fat indices and relative muscle CSA, that is, CSA void of fat. Right/left averages for levels L2 through L5 were determined. Mixed-design analyses of covariance were used to test for differences between groups, based on LBP presence and sex, across levels (P≤.05). Results Older adults with LBP had a greater average multifidus muscle-to-fat index (0.51 versus 0.49) and smaller average erector spinae relative muscle CSA (8.56 cm2 versus 9.26 cm2) when compared to control participants without LBP. No interactions between LBP status and average muscle characteristics were found for the psoas or quadratus lumborum (P>.05). Conclusion Up to 54% of older adult trunk muscle CSA may be fat. Women have smaller muscles and greater intramuscular fat (at lower spinal levels) than men. J Orthop Sports Phys Ther 2017;47(3):173-179. Epub 3 Feb 2017. doi:10.2519/jospt.2017.7002.

Lumbar Mobility and Performance-Based Function: An Investigation in Older Adults with and without Chronic Low Back Pain.

Objective: To explore potential differences in lumbar mobility between older adults with and without chronic low back pain, and to determine if lumbar mobility contributes to physical performance in both groups. We hypothesized that older adults with pain would have greater lumbar mobility impairments than pain-free peers, and that lumbar mobility would be associated with performance in both groups, with stronger relationships among those with pain. Design: Matched case-control. Setting: Research laboratory. Patients: Community-dwelling older adults, aged 60-85 years, with (N = 54) and without (N = 54) chronic low back pain. Methods: Inclinometer-measured maximal angles of lumbar flexion, extension, and average side-bending, as well as time to complete performance measures, Repeated Chair Rise and Timed-Up-and-Go, were measured in both groups. Analysis of variance was used to explore the difference in lumbar mobility between groups. Adjusted linear regression was used to assess the independent relationship between lumbar mobility and physical function in both groups. Results: Those with pain had smaller angles of flexion ( P = 0.029) and extension ( P = 0.013). In the pain group, flexion explained 19% ( P = 0.001) and 8.9% ( P = 0.006) of the variance for time to complete the Repeated Chair Rise and Timed Up-and-Go tests, respectively. In the pain-free group, extension explained 12.7% ( P = 0.007) and 10.3% ( P = 0.008) of the variance for time to complete Repeated Chair Rise and Timed Up-and-Go tests, respectively. Conclusion: Older adults with chronic low back pain have more lumbar mobility impairments. Lumbar mobility may be a contributing factor to decreased performance in older adults. Flexion may be most important to performance in those with pain, while extension may be vital in those without pain.

Multifidi Muscle Characteristics and Physical Function Among Older Adults With and Without Chronic Low Back Pain.

OBJECTIVE: To determine whether multifidi size, intramuscular fat, or both, are associated with self-reported and performance-based physical function in older adults with and without chronic low back pain (LBP). DESIGN: Case-control study. SETTING: Individuals participated in a standardized evaluation in a clinical laboratory and underwent magnetic resonance imaging (MRI) of the lumbar spine at a nearby facility. PARTICIPANTS: A volunteer sample of community-dwelling older adults (N=106), aged 60 to 85 years, with (n=57) and without (n=49) chronic LBP were included in this secondary data analysis. INTERVENTION: Average right-left L5 multifidi relative (ie, total) cross-sectional area (CSA), muscle-fat infiltration index (MFI) (ie, a measure of intramuscular fat), and relative muscle CSA (rmCSA) (ie, total CSA minus intramuscular fat CSA) were determined from MRIs. Linear regression modeling was performed with physical function measures as the dependent variables. Age, sex, and body mass index were entered as covariates. The main effects of L5 multifidi MFI and rmCSA, as well as their interaction with group assignment, were compared as independent variables. MAIN OUTCOME MEASURES: Medical Outcomes Study 36-Item Short-Form Health Survey physical functioning subscale, timed Up and Go, gait speed, and fast stair descent performance. RESULTS: Interaction terms between L5 multifidi MFI and group assignment were found to be significant contributors to the variance explained in all physical function measures (P≤.012). Neither the main effect nor the interaction with group assignment for L5 multifidi rmCSA significantly contributed to the variance explained in any of the physical function measures (P>.012). CONCLUSIONS: Among older adults with chronic LBP of at least moderate intensity, L5 multifidi muscle composition, but not size, may help to explain physical function.

Reliability of ultrasound imaging for the assessment of lumbar multifidi thickness in older adults with chronic low back pain.

BACKGROUND AND PURPOSE: Ultrasound imaging (USI) has been shown to be a reliable measure for direct assessment of the lumbar multifidi among younger adults. However, given age- and chronic low back pain (CLBP)-related spinal changes, similar studies are needed before clinical use of USI among older adults with CLBP. The goals of this study were to evaluate intra- and interexaminer reliability for USI assessment of multifidi thickness at rest and during a contraction and to determine standard error of measurement values (SEMs) and minimal detectable change values (MDCs) among older adults with CLBP. METHODS: Thirty-one adults, aged 60 to 85 years, with CLBP were recruited. Two examiners performed USI assessments of multifidus thickness at rest and during a contralateral lower extremity lift. Intraclass correlation coefficients (ICCs) were used to estimate inter- and intraexaminer reliability. Additionally, SEMs and MDCs were calculated. RESULTS: All USI measurement techniques demonstrated excellent within-day, interexaminer procedural reliability (ICCs: 0.82-0.85) and good-to-excellent between-day, interexaminer procedural reliability (ICCs: 0.72-0.79). The SEMs ranged from 0.36 to 0.46 cm; MDCs ranged from 1.01 to 1.26 cm. Regardless of the measurement technique, examiner 1, the more experienced examiner, demonstrated lower SEMs and MDCs than examiner 2. DISCUSSION: Lower ICCs, greater SEMs, and greater MDCs for USI multifidus thickness assessment in older adults with CLBP, when compared with previously published, procedural reliability results for younger adults with and without low back pain, may indicate that imaging is more challenging in this patient population. Factors, such as examiner training and participant anthropometrics, may impact reliability. CONCLUSIONS: Good-to-excellent intra- and interexaminer USI procedural reliability may provide clinicians a direct assessment technique for clinical evaluation of the lumbar multifidi in older adults with CLBP. SEMs and MDCs may allow for accurate interpretation of USI assessments in this population.

Ultrasound imaging: intraexaminer and interexaminer reliability for multifidus muscle thickness assessment in adults aged 60 to 85 years versus younger adults.

STUDY DESIGN: Intraexaminer and interexaminer, within- and between-day reliability study. OBJECTIVES: To compare the intraexaminer and interexaminer procedural reliability of ultrasound imaging (USI) thickness measurements of the lumbar multifidus muscle at rest and during a contralateral lower-limb lift (CLL) between older (60-85 years of age) and younger (18-40 years of age) adults. BACKGROUND: Among younger adults, USI has been shown to be reliable and valid for assessing multifidus thickness. Older adults present with age-related changes that may impact assessment. To our knowledge, no USI studies have focused on establishing reliability for multifidus thickness assessments in older adults. METHODS: Two examiners performed assessments of lumbar multifidus thickness at rest and during a CLL in 30 older and 31 younger adults. Intraclass correlation coefficient (ICC) with 95% confidence interval, standard error of measurement, 95% minimal detectable change for resting and during the CLL, and percent thickness change were calculated. RESULTS: Within-day interexaminer procedural reliability for multifidus thickness measurements was similar among younger (ICC = 0.90-0.92) and older adults (ICC = 0.86-0.90), as was between-day intraexaminer and interexaminer reliability (younger adults, ICC = 0.84-0.94; older adults, ICC = 0.86-0.93). Throughout, estimates of percent thickness change were inconsistent (ICC = 0.31-0.86), and standard errors of measurement and minimal detectable changes were larger for older adults. CONCLUSION: Ultrasound imaging reliability for measurements of multifidus thickness at rest and during a CLL among older adults is consistent with previously published findings for younger adults. Among older adults, it may be preferable to have a single examiner conduct USI assessments.

Fear-avoidance beliefs are associated with disability in older American adults with low back pain.

BACKGROUND: Although fear-avoidance beliefs (FABs) have been explored in younger adults and Spanish older adults, their relationships to measures of low back pain (LBP)-related disability, overall physical health, and falling have not been investigated in older American adults. OBJECTIVE: The purpose of this study was to examine the association of FABs with self-reported disability, physical health, and falling among community-dwelling older adults with LBP in the United States. DESIGN: This was a cross-sectional study. METHODS: Ninety-three community-dwelling men and women with current LBP were included in this analysis. Participants completed the Fear-Avoidance Beliefs Questionnaire physical activity subscale (FABQ-PA). The modified Oswestry Disability Questionnaire (mOSW) and the Quebec Back Pain Disability Scale (QUE) were used to measure self-reported disability, and the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire (SF-36) physical component summary (PCS) score was used to assess physical health. Participants provided demographic information and information regarding LBP duration and intensity. Linear regression models were developed using the following dependent variables: mOSW, QUE, and SF-36 PCS scores. Logistic regression was used to determine the association between high FABs and falling. RESULTS: For each analysis, the FABQ-PA score independently explained 3% to 6% of the variance in the LBP-related disability score and 3% of the variance in the SF-36 PCS score. For all dependent variables, the strongest contributors to explained variance were pain intensity, assistive device use, and FABQ-PA score. High FABs were associated with falling. LIMITATIONS: Future investigations might seek a more diversified sample and utilize both qualitative and quantitative measures for assessing disability and physical health. CONCLUSIONS: Physical activity FABs are independently associated with self-reported disability and overall physical health in older American adults with LBP. High FABs may warrant balance and falls assessment.