Disability reduction following a lumbar stabilization exercise program for low back pain: large vs. small improvement subgroup analyses of physical and psychological variables.

BACKGROUND: Little is known about why patients with low back pain (LBP) respond differently to treatment, and more specifically, to a lumbar stabilization exercise program. As a first step toward answering this question, the present study evaluates how subgroups of patients who demonstrate large and small clinical improvements differ in terms of physical and psychological changes during treatment. METHODS: Participants (n = 110) performed the exercise program (clinical sessions and home exercises) over eight weeks, with 100 retained at six-month follow-up. Physical measures (lumbar segmental instability, motor control impairments, range of motion, trunk muscle endurance and physical performance tests) were collected twice (baseline, end of treatment), while psychological measures (fear-avoidance beliefs, pain catastrophizing, psychological distress, illness perceptions, outcome expectations) were collected at four time points (baseline, mid-treatment, end of treatment, follow-up). The participants were divided into three subgroups (large, moderate and small clinical improvements) based on the change of perceived disability scores. ANOVA for repeated measure compared well-contrasted subgroups (large vs. small improvement) at different times to test for SUBGROUP × TIME interactions. RESULTS: Statistically significant interactions were observed for several physical and psychological measures. In all these interactions, the large- and small-improvement subgroups were equivalent at baseline, but the large-improvement subgroup showed more improvements over time compared to the small-improvement subgroup. For psychological measures only (fear-avoidance beliefs, pain catastrophizing, illness perceptions), between-group differences reached moderate to strong effect sizes, at the end of treatment and follow-up. CONCLUSIONS: The large-improvement subgroup showed more improvement than the small-improvement subgroup with regard to physical factors typically targeted by this specific exercise program as well as for psychological factors that are known to influence clinical outcomes.

Barriers and facilitators to lower extremity orthotic compliance in the pediatric population: A scoping review of the literature.

Despite the purported benefits of lower extremity orthotics in the literature, pediatric compliance rates remain low. This scoping review synthesized the available literature regarding barriers and facilitators to lower extremity orthotic compliance in the pediatric population using the framework of the International Classification of Functioning, Disability and Health: Children and Youth (ICF). A comprehensive search of MEDLINE, EMBASE, and CINAHL was conducted on May 11, 2021, and of PsycInfo on May 12, 2021. Article reference lists and gray literature were also searched. A total of 81 articles were included. Factors described in at least four articles were labeled as universal barriers or facilitators. In the International Classification of Functioning, Disability and Health: Children and Youth domain of Body Functions/Body Structures, universal barriers were present in the global mental functions, experience of self and time, sensory functions, function of joints and bones, and structures related to the skin subcategories, with no universal facilitators identified. For the Activity Limitations/Participation Restrictions domain, one universal facilitator was identified in the mobility subcategory. In the Environmental Contextual Factors domain, universal barriers were found in the attitudes of immediate and extended family and societal attitude subcategories, with both universal barriers and facilitators found in support & relationships: immediate and extended family, support and relationships: health professionals, services, systems, and policies, and products and technology. The reviewed literature strongly emphasizes the importance of proper orthotic fit and comfort, and the child's experience of self, for lower extremity orthotic compliance, along with multiple environmental factors.

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.

Derivation of clinical prediction rules for identifying patients with non-acute low back pain who respond best to a lumbar stabilization exercise program at post-treatment and six-month follow-up.

Low back pain (LBP) remains one of the most common and incapacitating health conditions worldwide. Clinical guidelines recommend exercise programs after the acute phase, but clinical effects are modest when assessed at a population level. Research needs to determine who is likely to benefit from specific exercise interventions, based on clinical presentation. This study aimed to derive clinical prediction rules (CPRs) for treatment success, using a lumbar stabilization exercise program (LSEP), at the end of treatment and at six-month follow-up. The eight-week LSEP, including clinical sessions and home exercises, was completed by 110 participants with non-acute LBP, with 100 retained at the six-month follow-up. Physical (lumbar segmental instability, motor control impairments, posture and range of motion, trunk muscle endurance and physical performance tests) and psychological (related to fear-avoidance and home-exercise adherence) measures were collected at a baseline clinical exam. Multivariate logistic regression models were used to predict clinical success, as defined by ≥50% decrease in the Oswestry Disability Index. CPRs were derived for success at program completion (T8) and six-month follow-up (T34), negotiating between predictive ability and clinical usability. The chosen CPRs contained four (T8) and three (T34) clinical tests, all theoretically related to spinal instability, making these CPRs specific to the treatment provided (LSEP). The chosen CPRs provided a positive likelihood ratio of 17.9 (T8) and 8.2 (T34), when two or more tests were positive. When applying these CPRs, the probability of treatment success rose from 49% to 96% at T8 and from 53% to 92% at T34. These results support the further development of these CPRs by proceeding to the validation stage.

The Relationship Between Pain-Related Threat and Motor Behavior in Nonspecific Low Back Pain: A Systematic Review and Meta-Analysis.

OBJECTIVE: Although pain-related fear and catastrophizing are predictors of disability in low back pain (LBP), their relationship with guarded motor behavior is unclear. The aim of this meta-analysis was to determine the relationship between pain-related threat (via pain-related fear and catastrophizing) and motor behavior during functional tasks in adults with LBP. METHODS: This review followed PRISMA guidelines. MEDLINE, Embase, PsychINFO, and CINAHL databases were searched to April 2021. Included studies measured the association between pain-related fear or pain catastrophizing and motor behavior (spinal range of motion, trunk coordination and variability, muscle activity) during movement in adults with nonspecific LBP. Studies were excluded if participants were postsurgery or diagnosed with specific LBP. Two independent reviewers extracted all data. The Newcastle-Ottawa Scale was used to assess for risk of bias. Correlation coefficients were pooled using the random-effects model. RESULTS: Reduced spinal range of motion during flexion tasks was weakly related to pain-related fear (15 studies, r = -0.21, 95% CI = -0.31 to -0.11) and pain catastrophizing (7 studies, r = -0.24, 95% CI = -0.38 to -0.087). Pain-related fear was unrelated to spinal extension (3 studies, r = -0.16, 95% CI = -0.33 to 0.026). Greater trunk extensor muscle activity during bending was moderately related to pain-related fear (2 studies, r = -0.40, 95% CI = -0.55 to -0.23). Pain catastrophizing, but not fear, was related to higher trunk activity during gait (2 studies, r = 0.25, 95% CI = 0.063 to 0.42). Methodological differences and missing data limited robust syntheses of studies examining muscle activity, so these findings should be interpreted carefully. CONCLUSION: This study found a weak to moderate relationship between pain-related threat and guarded motor behavior during flexion-based tasks, but not consistently during other movements. IMPACT: These findings provide a jumping-off point for future clinical research to explore the advantages of integrated treatment strategies that target both psychological and motor behavior processes compared with traditional approaches.

Interrater Reliability among Novice Raters in the Assessment of Pelvic Floor Muscle Tone Using the Reissing Tone Scale.

Purpose: The authors sought to determine the interrater reliability among novice raters of intra-vaginal manual assessment of pubococcygeus muscle tone in women using the Reissing tone scale (RTS). Method: Three graduating physiotherapy students (novice raters) and one experienced pelvic floor physiotherapist assessed 31 female participants (aged 20-66 y). Assessors gave RTS scores for pubococcygeus tone at three intra-vaginal locations (6:00, 9:00, and 3:00). Interrater reliability was determined for the novice raters using a two-way random single-measures absolute agreement intra-class correlation coefficient (ICC). Spearman rank correlation (SRC) analysis determined the correlation between the novice and expert scores. Results: The ICC values for the novice raters were 0.523, 0.274, and 0.336 at 6:00, 9:00, and 3:00, and the SRC values between the novice and expert raters were 0.580, 0.320, and 0.340. Conclusions: The novice raters demonstrated low to moderate interrater reliability for intra-vaginal manual assessment of pubococcygeus tone. This result indicates that manual assessment of pelvic floor muscle tone is not reliable enough to use as a stand-alone test to guide treatment, at least for physiotherapists with limited clinical experience.

Objectif : déterminer la fiabilité interévaluateur des évaluateurs novices qui procèdent à l'évaluation intravaginale manuelle du tonus musculaire pubo-coccygien au moyen du score de tonus de Reissing (STR). Méthodologie : trois étudiants en physiothérapie finissants (les évaluateurs novices) et un physiothérapeute périnéal d'expérience ont évalué 31 participantes (âgées de 20 à 66 ans). Ils ont attribué un STR au tonus pubo-coccygien à trois foyers intravaginaux (à 6, 9 et 3 heures). Les chercheurs ont déterminé la fiabilité interévaluateur des évaluateurs novices au moyen d'un coefficient intraclasse de corrélation (CIC) à concordance absolue des mesures simples bidirectionnelles randomisées. Les chercheurs ont analysé la corrélation de Spearman (CdS) pour établir le lien entre les scores des novices et de l'expert. Résultats : la CIC des évaluateurs novices s'élevait à 0,523, 0,274 et 0,336 à 6, 9 et 3 heures, respectivement, et la CdS entre les évaluateurs novices et expert s'établissait à 0,580, 0,320 et 0,340. Conclusion : les évaluateurs novices ont démontré une fiabilité interévaluateur faible à modérée lors de l'évaluation intravaginale manuelle du tonus pubo-coccygien. Ainsi, l'évaluation manuelle du tonus périnéal n'est pas assez fiable si elle est utilisée seule pour orienter le traitement, du moins chez les physiothérapeutes ayant une expérience clinique limitée.

Quadriceps and Hamstring Strength in Adolescents 6 Months After ACL Reconstruction With Femoral Nerve Block, Adductor Canal Block, or No Nerve Block.

BACKGROUND: Femoral nerve block (FNB) and adductor canal block (ACB) have been used increasingly for pain control during anterior cruciate ligament (ACL) reconstruction in adolescent patients. However, recent evidence suggests that the use of FNB may affect quadriceps strength recovery 6 months after surgery. PURPOSE/HYPOTHESIS: To compare postoperative isokinetic strength in adolescents who received FNB, ACB, or no block for perioperative analgesia during ACL reconstruction. We anticipated lower postoperative quadriceps and hamstring isokinetic deficits in adolescents who received FNB as compared with ACB. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients were included in the study if they had undergone hamstring tendon autograft ACL reconstruction by a single surgeon from July 2008 to January 2018 and if they underwent isokinetic muscle testing at 4 to 8 months postoperatively. The participants were divided into 3 groups (no block, FNB, and ACB), and we compared the deficit in percentages between the affected and unaffected limbs as calculated from the isokinetic quadriceps and hamstring strength testing at 60 and 180 deg/s. Between-group analysis was performed using analysis of variance, with an alpha of .05. RESULTS: A total of 98 participants were included in the analysis (31 no block, 36 FNB, and 31 ACB). The mean ± SD age of the patients was 15.26 ± 1.15, 15.50 ± 1.42, and 15.71 ± 1.44, for no block, FNB, and ACB, respectively. At 5.61 months postoperatively, there was no significant difference across the 3 groups in isokinetic quadriceps deficits (P ≥ .99), and the only significant difference in isokinetic hamstring deficit was observed for peak flexion at 180 deg/s, in which the ACB group had lower peak torque than the FNB group (-9.80% ± 3.48% vs 2.37% ± 3.23%; P = .035). The ratio of participants with a deficit exceeding 15% did not differ significantly among the 3 groups. CONCLUSION: Contrary to previous research, our findings indicate only minimal difference in quadriceps strength among the 3 types of perioperative analgesia in adolescents approximately 6 months after ACL reconstruction. The only significant strength deficit was seen in the hamstrings of patients receiving ACB at peak flexion as compared with those receiving FNB.

Structural remodeling of the lumbar multifidus, thoracolumbar fascia and lateral abdominal wall perimuscular connective tissues: Medium-term test-retest reliability of ultrasound measures.

INTRODUCTION: Growing interest is being paid to the lumbar multifidus (LM) intramuscular fatty infiltrations and fibrosis that are secondary to low back pain as well to the remodeling of perimuscular connective tissues (fasciae) such as the thoracolumbar fascia and fascia sheets separating the abdominal wall muscles. Magnetic resonance imaging and computed tomography have traditionally been used but rehabilitative ultrasound imaging (RUSI) is much more affordable and practical, which can accelerate research and clinical applications on this topic. The aim of this study was to test the medium-term (8 weeks) test-retest reliability of the corresponding RUSI measures. METHODS: Thirty-four participants with non-acute LBP and 30 healthy controls performed a RUSI assessment before and after an 8-week time interval. LM echogenicity was quantified to assess fatty infiltrations and fibrosis while fasciae were quantified with thickness measures. Relative and absolute reliability were estimated using the generalizability theory as a framework, allowing to partition the different sources of error. RESULTS: Overall, the reliability findings were quite acceptable, with negligible systematic effects. Excellent relative reliability was reached in half of the investigated RUSI measures, particularly when averaging measures across trials. However, neither relative, nor absolute reliability results support the use of these RUSI measurements on an individual basis (e.g. clinical applications) but they are useful on a group basis (e.g. research applications). DISCUSSION: The different sources of error were distributed unequally across RUSI measures, pointing to different measurement strategies to mitigate the underlying errors. CONCLUSIONS: The use of the generalizability theory allowed identifying the sources of error of the different RUSI measures. For each category of measure, depending of the distribution of errors, it was possible to recommend specific measurement strategies to mitigate them.

The effect of extensible and non-extensible lumbosacral orthoses on anticipatory postural adjustments in participants with low back pain and healthy controls.

BACKGROUND: Wearing a lumbosacral orthosis (LSO) is known to influence spine mechanics, but less is known about how LSOs affect motor control. Whether the use of a LSO can negatively affect motor control of the lumbar spine is still under debate. OBJECTIVE: The current study examined the immediate effects of two flexible LSOs (extensible and non-extensible) on the anticipatory postural adjustments that prepare the spine for a predictable perturbation. DESIGN: A comparative study using a repeated measures design in a laboratory setting. METHODS: Healthy controls (n = 20) and participants with low back pain (n = 40) performed a rapid arm flexion/extension cycle with and without these LSOs. The latency between the activations of the shoulder and different back (iliocostalis lumborum) and abdominal (rectus abdominis, internal and external obliques) muscles, as measured with surface electromyography, was used as the outcome. RESULTS: The effects, which were comparable between groups and between LSOs, were mixed, with some muscles showing significantly (p ˂ 0.05) earlier activation and others showing delayed activation with the use of a LSO, relative to the control condition. The corresponding effect sizes were low to average (Hedges's g range: 0.17-0.48). CONCLUSIONS: These findings suggest a change in the motor program before task initiation, which might be generalizable to other activities of daily living or work. However, none of the effects were large, making it difficult to provide clear conclusions with regard to their clinical relevance. It remains to be tested whether these immediate adaptations in motor planning can induce long term detrimental effects to the control of lumbar stability.

Structural remodeling of the lumbar multifidus, thoracolumbar fascia and lateral abdominal wall perimuscular connective tissues: A search for its potential determinants.

Recently remodeling of lumbar soft tissues has received increased research attention. However, the major determinants that influence remodeling need to be elucidated in order to understand the impact of different rehabilitation modalities on tissue remodeling. The main aim of this study was to explore the between-subject variance of different measures of lumbar soft tissues quantified with rehabilitative ultrasound imaging (RUSI). RUSI measures (n = 8) were collected from 30 subjects without and 34 patients with LBP: (1) lumbar multifidus (LM) echogenicity (fatty infiltration/fibrosis) at three vertebral levels (L3/L4, L4/L5 and L5/S1) (n = 3); (2) posterior layer thickness of the thoracolumbar fascia (n = 1); and (3) thickness of the fasciae surrounding the external oblique (EO), internal oblique (IO), and transversus abdominis (TrA) (n = 4). Forward stepwise multivariate regression modeling was conducted with these RUSI measures as dependent variables, using the following independent variables as potential determinants: age, sex, the presence of LBP, body size/composition characteristics (height, weight, trunk length, subcutaneous tissue thickness over the abdominal, and LM muscles), trunk muscle function (or activation) as determined with the percent thickness change of LM, EO, IO, and TrA muscles during a standardized effort (RUSI measures), and physical activity level during sport and leisure activities as estimated with a self-report questionnaire. Two or three statistically significant predictors (or determinants) were selected in the regression model of each RUSI measure (n = 8 models), accounting for 26-64% of their total variance. The subcutaneous tissue thickness on the back accounted for 15-30% variance of LM echogenicity measures and thoracolumbar fascia thickness while the subcutaneous tissue thickness over the abdominals accounted for up to 42% variance of the fascia separating the subcutaneous adipose tissues and the EO muscle. The thickness of IO at rest accounted for 13-21% variance of all investigated abdominal fasciae except the fascia separating the subcutaneous adipose tissue and EO. Pain status accounted for 13-18% variance of the anterior and posterior fasciae of the TrA. Age accounted for 11-14% variance of LM echogenicity at all investigated vertebral levels while sex accounted for 15-21% variance of LM echogenicity at L3/L4 and fascia separating subcutaneous adipose tissue and EO muscle. The function (or activation) of EO and LM at L3/L4 accounted for 8-11% variance of the thoracolumbar fascia and fascia separating TrA and intra-abdominal content (TrA posterior fascia), respectively. Finally, the physical activity level during sport activities accounted for 7% variance of the fascia separating the subcutaneous adipose tissues and the EO muscle. These findings suggest that determinants other than body size characteristics may impact the remodeling of lumbar soft tissues, more importantly the subcutaneous adipose tissue deposits (thickness RUSI measures), which are associated with ectopic fat deposition in the LM and in the fasciae that are more closely positioned to the surface. While age, sex, and pain status explain some variability, modifiable factors such as physical activity level as well as trunk muscle thickness and function were involved. Overall, these results suggest that rehabilitation can potentially impact tissue remodeling, particularly in terms of intramuscular and perimuscular adipose tissues.

Structural remodelling of the lumbar multifidus, thoracolumbar fascia and lateral abdominal wall perimuscular connective tissues: A cross-sectional and comparative ultrasound study.

INTRODUCTION: With low back pain (LBP), remodelling of the lumbar soft tissues involves both trunk muscles and neighbouring passive connective tissues. The aim of the present study was to compare three quantitative measures of these tissues, using ultrasound imaging (USI), among healthy controls and individuals with LBP. METHODS: USI measures from 30 healthy subjects and 34 patients with non-acute LBP were compared between groups and sexes. The measures employed were (1) lumbar multifidus echogenicity (fatty/fibrosis infiltration) at three vertebral levels; (2) posterior layer thickness of the thoracolumbar fascia, and (3) thickness of the perimuscular tissues surrounding the external oblique, internal oblique and transversus abdominis (TrA). RESULTS: USI measures of (1) multifidus echogenicity showed statistically significant changes between vertebral levels and sexes (females > males; p = 0.02); (2) differences in thoracolumbar fascia thickness approached statistical significance between groups (LBP > controls; p = 0.09) and sexes (females < males; p = 0.07); and (3) perimuscular tissue surrounding the TrA was significantly thinner (p ≤ 0.001) in patients with LBP compared to controls. DISCUSSION: The thinner perimuscular tissues surrounding the TrA in patients with LBP is a new finding, concurring with previous findings with regard to the lower activation of this deep muscle as well as more recent findings on other perimuscular tissue. CONCLUSION: Overall, USI measures were sensitive to different potential changes (pain status, sex, vertebral level), and this is useful in studying the remodelling of various soft tissues of the trunk.

Is postural control during unstable sitting a proxy measure for determinants associated with lumbar stability?

The aim of this study was to test whether determinants associated with lumbar stability can predict performance during unstable sitting (trunk postural control - TPC). If confirmed, unstable sitting could be viewed as a proxy measure for these determinants. Wobbling chair motion was measured in 58 subjects with an inertial sensor, and six outcomes were computed (mean frequency and velocity, frequency dispersion, two variables from the sway density analysis and Lyapunov exponent - short interval) to represent TPC performance. Subjects also performed five other trunk neuromuscular tests to quantify the thickness of back and abdominal muscles and connective tissues, lumbar proprioception, lumbar stiffness, feedforward and feedback control mechanisms, and trunk/muscle coordination. Four to five predictors explained between 36 and 47% of TPC outcomes variance, as determined with multivariate analyses. These predictors were mainly related to (1) angular kinematic parameters of the pelvis or lumbar spine following rapid arm movement, (2) lumbar intrinsic stiffness, (3) thickness of perimuscular connective tissues surrounding specific abdominal muscles, (4) activation onsets of specific trunk muscles (IO/TrA and iliocostalis lumborum) before rapid arm movement, and (5) percent thickness change of internal oblique (IO) and transversus abdominis (TrA) muscles. Lumbar proprioception and reflex responses were not predictive, possibly due to the lack of appropriate measurements. These findings support the use of TPC in unstable sitting as a proxy measure for determinants associated with lumbar stability. This might be useful in research and clinical settings, considering time and equipment constraints associated with measuring these determinants individually.

The effect of extensible and non-extensible lumbar belts on trunk postural balance in subjects with low back pain and healthy controls.

BACKGROUND: Previous findings suggest that wearing a lumbar belt may benefit some patients with low back pain; however, the mechanisms of action are not yet fully understood. RESEARCH QUESTION: The effect of wearing two flexible (extensible and non-extensible) lumbar belts on trunk postural control was investigated during an unstable sitting task. METHODS: Healthy subjects and subjects with LBP sat on a wobbling chair, with and without the lumbar belts. Chair rotation was measured in the sagittal and frontal planes, and 10 linear and nonlinear measures of balance were computed to assess the quantity (3 measures) and quality (7 measures) of the movements. RESULTS: Both lumbar belts induced similar changes in specific measures of trunk postural control, for both subject groups, generally indicative of more instability and less controllability, but with low effect sizes (0.14 and 0.40). Subjects with LBP also showed lower entropy (complexity; effect size 0.93) and higher determinism (predictability; effect size 0.56) than healthy controls, under all test conditions. These findings indicate that the subjects with LBP used a less complex, more predictable trunk postural control strategy, suggestive of impaired adaptability and responsiveness to dynamic trunk postural control demands. The findings also suggest other factors related to dynamic adaptability may be impaired by lumbar belt use. SIGNIFICANCE: The effects of the lumbar belts on trunk postural control were small, however, their practical implications for the management of LBP remain to be determined in relation to other effects of lumbar belts (e.g. increased mechanical stiffness).

The effect of extensible and non-extensible lumbar belts on trunk muscle activity and lumbar stiffness in subjects with and without low-back pain.

BACKGROUND: Lumbar belts have been shown to increase lumbar stiffness, but it is unclear if this is associated with trunk muscle co-contraction, which would increase the compression on the spine. It has been hypothesized that lumbar belts increase lumbar stiffness by increasing intra-abdominal pressure, which would increase spinal stability without increasing the compressive load on the spine. METHODS: Trunk muscle activity and lumbar stiffness and damping were measured in healthy and low-back pain subjects during three conditions: no lumbar belt; wearing an extensible lumbar belt; wearing a non-extensible lumbar belt. Muscle activity was measured while subjects performed controlled forward and backward 20° trunk sways. Lumbar stiffness and damping were measured by applying random continuous perturbation to the chest. FINDINGS: External oblique activity was decreased when wearing either lumbar belt during all phases of movement, while rectus abdominis and iliocostalis activity were decreased during the phase of movement where the muscles were maximally active while wearing either belt. Trunk stiffness was greatly increased by wearing either belt. There were no consistent differences in either lumbar stiffness or muscle activity between the two belts. Wearing a lumbar belt had little to no effect on damping. There were no group differences in any of the measures between healthy and low-back pain populations. INTERPRETATION: The findings are consistent with the hypothesis that lumbar belts can increase spinal stability by increasing intra-abdominal pressure, without any increase in the compressive load on the spine. The findings can also be generalized, for the first time, to subjects with low-back pain.

The Effects of Data Padding Techniques on Continuous Relative-Phase Analysis Using the Hilbert Transform.

Continuous relative phase (CRP) analysis using the Hilbert transform is prone to end effects. The purpose was to investigate the impact of padding techniques (reflection, spline extrapolation, extraneous data, and unpadded) on end effects following Hilbert-transformed CRP calculations, using sinusoidal, nonsinusoidal, and kinematic data from a repeated sit-to-stand-to-sit task in adults with low back pain (n = 16, mean age = 30 y). CRP angles were determined using a Hilbert transform of sinusoidal and nonsinusoidal signals with set phase shifts, and for the left thigh/sacrum segments. Root mean square difference and true error compared test signals with a gold standard, for the start, end, and full periods, for all data. Mean difference and 95% bootstrapped confidence intervals were calculated to compare padding techniques using kinematic data. The unpadded approach showed near-negligible error using sinusoidal data across all periods. No approach was clearly superior for nonsinusoidal data. Spline extrapolation showed significantly less root mean square difference (all periods) when compared with double reflection (full period: mean difference = 2.11; 95% confidence interval, 1.41 to 2.79) and unpadded approaches (full period: mean difference = -15.8; 95% confidence interval, -18.9 to -12.8). Padding sinusoidal data when performing CRP analyses are unnecessary. When extraneous data have not been collected, our findings recommend padding using a spline to minimize data distortion following Hilbert-transformed CRP analyses.

Ultrasound Measures of the Abdominal Wall in Patients with Low Back Pain Before and After an 8-week Lumbar Stabilization Exercise Program, and Their Association With Clinical Outcomes.

BACKGROUND: Lumbar stabilization exercise programs (LSEPs) act positively on clinical outcome measures in patients with low back pain (LBP), but the underlying mechanisms are not well understood. Among the various neuromuscular mechanisms, a good candidate is better activation of the abdominal wall, as measured with rehabilitative ultrasound imaging (RUSI). OBJECTIVES: To determine whether RUSI measures are (1) sensitive to LBP status and treatment (LSEP) and (2) correlate with clinical outcomes following the LSEP. DESIGN: An exploratory one-arm clinical trial with healthy participants as a control group. SETTING: LSEP was delivered in a clinical setting; outcomes were measured in a laboratory setting. PARTICIPANTS: Thirty-one patients with nonacute LBP and 30 healthy controls. METHODS: Outcome measures were performed before and after an 8-week LSEP in patients with LBP, and with the same time interval for control participants to compare with patients at baseline. MAIN OUTCOME MEASUREMENTS: Pain, disability, as well as static (at rest) and dynamic (percent thickness change) RUSI measures for abdominal muscles (transversus abdominis, internal oblique [IO], and external oblique [EO]). RESULTS: Patients did not produce systematic changes in RUSI measures relative to controls, even if patients had significant improvement in pain and disability. However, the correlational analyses between the absolute change (pre- to post-LSEP) (1) of EO and IO thickness (in mm) at rest (bilaterally), and (2) in pain following the LSEP were significant and consistent (range: .36-.45) in patients. CONCLUSIONS: Although positive clinical improvements were observed following LSEP, there were minimal systematic changes in RUSI measures, likely because patients were not different from controls at baseline. Correlational analyses, however, indicated that greater reductions in pain were associated with reduced thickness of the EO and IO following the LSEP, suggesting the presence of some heterogeneity (or clinical subgroups) among the patients. LEVEL OF EVIDENCE: II.

Muscular co-contraction is related to varus thrust in patients with knee osteoarthritis.

BACKGROUND: Patients with knee osteoarthritis often present with varus thrust and muscular co-contraction during gait. It is unclear if these adaptations are related. The objective was to examine the relationship between muscle co-contraction and varus thrust during gait in patients with knee osteoarthritis and to determine if these relationships are modulated by disease severity or history of knee ligament rupture. METHODS: Participants (n = 42, 23 women, mean age 58 years) with knee osteoarthritis completed gait trials at self-selected speeds. Varus thrust was measured with an eight camera motion capture system sampled at 100 Hz. Co-contraction ratios were measured with surface electromyography sampled at 2000 Hz over the quadriceps, hamstrings, and gastrocnemius. Disease severity was measured on radiographs and history of anterior cruciate ligament rupture was confirmed on magnetic resonance imaging. Linear regression analyses examined the relationship between varus thrust and co-contraction ratios after controlling for radiographic disease severity and history of anterior cruciate ligament rupture. FINDINGS: Higher vastus lateralis-lateral hamstring (b = 0.081, P < 0.001; R2 = 0.353) and vastus medialis-medial hamstring (b = 0.063, P = 0.028; R2 = 0.168) co-contraction ratios were associated with greater varus thrust. Quadriceps-gastrocnemius co-contractions ratios were not related to varus thrust (P > 0.05). Radiographic disease severity or history of anterior cruciate ligament injury did not significantly contribute to regression models. INTERPRETATION: Greater quadriceps-hamstring co-contraction is associated with greater varus thrust in patients with knee osteoarthritis. Potential explanations include increased co-contraction may provide stability or there is a proprioceptive reflex that is independent of any stabilizing role. Research is needed to test these hypotheses.

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

BACKGROUND: Differences 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. METHODS: Participants 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. FINDINGS: Across 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. INTERPRETATION: Excessive 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.

Optimal Estimation of Anthropometric Parameters for Quantifying Multisegment Trunk Kinetics.

Kinetics assessment of the human head-arms-trunk (HAT) complex via a multisegment model is a useful tool for objective clinical evaluation of several pathological conditions. Inaccuracies in body segment parameters (BSPs) are a major source of uncertainty in the estimation of the joint moments associated with the multisegment HAT. Given the large intersubject variability, there is currently no comprehensive database for the estimation of BSPs for the HAT. We propose a nonlinear, multistep, optimization-based, noninvasive method for estimating individual-specific BSPs and calculating joint moments in a multisegment HAT model. Eleven nondisabled individuals participated in a trunk-bending experiment and their body motion was recorded using cameras and a force plate. A seven-segment model of the HAT was reconstructed for each participant. An initial guess of the BSPs was obtained by individual-specific scaling of the BSPs calculated from the male visible human (MVH) images. The intersegmental moments were calculated using both bottom-up and top-down inverse dynamics approaches. Our proposed method adjusted the scaled BSPs and center of pressure (COP) offsets to estimate optimal individual-specific BSPs that minimize the difference between the moments obtained by top-down and bottom-up inverse dynamics approaches. Our results indicate that the proposed method reduced the error in the net joint moment estimation (defined as the difference between the net joint moment calculated via bottom-up and top-down approaches) by 79.3% (median among participants). Our proposed method enables an optimized estimation of individual-specific BSPs and, consequently, a less erroneous assessment of the three-dimensional (3D) kinetics of a multisegment HAT model.

The Effect of Stance Width and Anthropometrics on Joint Range of Motion in the Lower Extremities during a Back Squat.

The purpose of this study was to assess whether changing the stance width has an effect on the range of motion of hip flexion, knee flexion, and ankle dorsiflexion during an unloaded back squat, and whether these joint movements are affected by anthropometric differences. Thirty-two healthy, young adults performed unloaded back squats at three different stance widths, normalized to pelvic width. Joint angles were assessed using electromagnetic motion capture sensors on the sacrum, and thigh, shank and foot of the dominant leg. ANOVA comparison of joint angles for the three stance widths, at 10° intervals of thigh orientation during the squat, indicated that joint angles tended to be larger when stance width was narrower, with the most significant effects on ankle dorsiflexion. A greater trunk/thigh length ratio (relatively long trunk) also tended to be associated with lower ankle and knee angles, while a greater thigh/shank length ratio (relatively long thigh) tended to be associated with higher ankle and knee angles, for the two narrower stance widths. The most practical implication of our findings is that individuals with limited ankle dorsiflexion, or with particularly long legs / thighs, may benefit from a wider stance width when squatting.