Biomechanical assessments of lumbar spinal function. how low back pain sufferers differ from normals. implications for outcome measures research. part i: kinematic assessments of lumbar function

doi:10.1016/j.jmpt.2003.11.007

Journal of Manipulative and Physiological Therapeutics

Volume 27, Issue 1, January 2004, Pages 57-62

https://doi.org/10.1016/j.jmpt.2003.11.007 Get rights and content

Abstract

Objective

To review new and advanced biomechanical assessment techniques for the lumbar spine and illustrate the differences in lumbar function in patients with low back pain and asymtomatic subjects.

Data sources

The biomedical literature was searched for research and reviews on spinal kinematic differences between low back pain subjects and healthy controls. A data search for articles indexed on MEDLINE until April 2002 was performed.

Results

Kinematic measurements of lumbar function were categorized into 3 areas where low back patients may differ from normals: (1) end range of motion during simple movements; (2) higher order kinematics (displacement, velocity, and acceleration) during complex movement tasks; and (3) spinal proprioception. The assessment of higher order kinematics during complex movement tasks is the most highly researched and the most successful in describing differences between the populations. The use of simple end range of motion appears questionable, while assessing spinal proprioception is the least researched, yet shows potential in highlighting differences between low back sufferers and asymptomatics.

Conclusion

Current kinematic biomechanical assessment techniques are capable of identifying functional differences between low back pain populations and controls. The use and validity of the majority of these techniques as outcome measures are currently unknown, yet may be valuable in generating functional diagnoses, evaluating the mechanisms of current therapies, and prescribing specific rehabilitation programs.

Introduction

Assessing and identifying lumbar spine dysfunction in patients with low back pain (LBP) is necessary in the development of objective outcome measures of spinal function. If, as previously postulated, an anatomical diagnosis for low back conditions is impossible 80% to 90% of the time,¹ being able to differentiate normal spinal function from what is abnormal may be fundamental in creating a diagnosis based on spinal function rather than aberrant anatomy. A diagnosis based on function via tools and techniques to quantify dysfunction provides a means to assess a patient's current condition separate from their subjective perception of pain. Although presently unknown, biomechanical assessment techniques that categorize patients with different functional characteristics may help determine the patients which respond best to different therapies. It is possible that patients with low back pain may have completely different functional inadequacies and only the use of advanced assessments of spine function will describe and identify these dysfunctions. It is then possible that patients with different functional inadequacies may respond better to treatment aimed at correcting their functional limitations. Currently, this is unknown and future research using these biomechanical assessment techniques can address these possibilities. Additionally, biomechanical assessment techniques may provide insight into the various physiological effects of commonly used chiropractic therapeutics that may currently lack an identified mechanism for their clinical effectiveness (ie, spinal manipulation, specific exercise programs, physical therapy modalities).

The aim of this review is to introduce the reader to new biomechanical assessment techniques for the lumbar spine. This article will not thoroughly review traditional outcome measures (end range of motion [ROM], trunk strength, simple measures of trunk muscle electromyographic [EMG] amplitude, pain scoring, and motion palpation). Rather, this article will review biomechanical assessment techniques that are currently used in spine biomechanics laboratories, yet have not been used as outcome measures in the clinical research investigating chiropractic therapy. The biomechanical differences that evidence themselves using these biomechanical assessment techniques between patients with low back pain and pain-free controls will be reviewed. I hope that with future research many of these assessment techniques could be incorporated into clinical research and practice to improve the assessment of spinal function and possibly improve or validate therapy. This review is limited to noninvasive biomechanical measurement procedures. For the most part, investigations using imaging techniques or needle electromyograms are not reviewed; nor will this review assess motion or static palpation of lumbar musculature or joints of the spine. It is the intent of this review to provide the clinician and researcher with an introduction to the current and latest techniques used to assess spinal function and the manner in which low back injury has been documented to influence the measurable function of the lumbar spine.

For this article, biomechanical assessment techniques will be split into 2 broad categories: kinematic measures of lumbar function and electromyographic measures of lumbar function (companion part II paper).

Section snippets

Kinematic measures of lumbar function

Kinematic assessments of lumbar function require the measurement of the position of the lumbar spine in space. This is typically done through 2 means: video analysis and electrogoniometer techniques. Both methods can provide 3-dimensional dynamic tracking of spinal movements. These measures of spinal movement are that of spinal regions, ie, the lumbar spine, rather than individual motion segment movement. In addition to simple end range of motion, these techniques can provide a movement profile

Conclusion

By documenting the spinal higher order kinematics and proprioception, patients may be able to be categorized based on these functional parameters. Rehabilitation programs may be designed to specifically target these dysfunctions once it is determined which type of rehabilitation interventions best influence specific characteristics of spinal function. Perhaps a patient only has proprioceptive deficits but no higher order kinematic deficits. Treatment can be appropriately tailored. Or, with

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Quantitative dynamic wearable motion-based metric compared to patient-reported outcomes as indicators of functional recovery after lumbar fusion surgery
2022, Clinical Biomechanics
Citation Excerpt :
The cLMM assessment provides a standardized, reliable, direct measurement of lumbar function, which can easily be administered in clinical settings to gauge a patient's functional recovery. Lumbar RoM is frequently used in clinical diagnosis of cLBP despite its questionable utility as an effective outcome and its poor ability to discriminate between healthy controls and cLBP patients (Lehman, 2004; Marras et al., 1995; Marras et al., 1999; Poitras et al., 2000; Zuberbier et al., 2001). A significant attribute of the pN score is that it is derived from dynamic features of lumbar spine kinematics (such as velocities and accelerations) which have been shown to be better functional indicators than RoM.
Low back pain is a debilitating condition with poor patient outcomes despite the use of a wide variety of diagnostic and treatment modalities. A lack of objective metrics to support clinical decision-making may be a reason for these poor outcomes. This study aimed to compare patient recovery following lumbar fusion surgery using an objective motion-based metric (functional performance) and subjective patient-reported outcomes for pain, disability and kinesophobia.
A prospective observational study was conducted on 121 patients that received a lumbar fusion surgery. A wearable motion system was used to quantify three-dimensional multi-planar lumbar motion and benchmark each patient's lumbar function prior to surgery and post-operatively at follow-up time points for up to 2 years. Patient recovery profiles after surgery were evaluated using the acquired functional motion data and compared to patient-reported outcomes.
Our results found significant improvement after surgery in objective functional performance as well as patient-reported pain, disability, and kinesophobia. However, we found a delayed response in the objective metric, with meaningful improvement occurring only 6 months after fusion surgery. In contrast, we found significant improvement in all subjective scores as early as 6 weeks post-surgery.
Objective motion-based metric provides a unique perspective to assessing patient's functional recovery. While it is associated with dimensions of pain, disability and fear avoidance, it is also distinct and assesses a uniquely different dimension of functional health. This information can form the basis for the use of objective metrics to gauge patient recovery after lumbar fusion surgery.
Distinguishing between typical and atypical motion patterns amongst healthy individuals during a constrained spine flexion task
2019, Journal of Biomechanics
Citation Excerpt :
In general, substantial amounts of variation are observed within healthy and patient populations in neutral standing, flexed postures, and ranges of motion (Pearcy, 1985; Hayes et al., 1989; Miyasaka et al., 2000). Dynamic measures of lumbar spine movement have been shown to be more sensitive for differentiating between patient populations than static measures (Lehman, 2004). It would be beneficial to better understand how static postures such as neutral standing and full flexion influence dynamic motion between these endpoints and the natural variability associated with spine motion.
Despite ‘abnormal’ motion being considered a risk factor for low back injury, the current understanding of ‘normal’ spine motion is limited. Identifying normal motion within an individual is complicated by the considerable variation in movement patterns amongst healthy individuals. Therefore, the purpose of this study was to characterize sources of variation in spine motion among a sample of healthy participants. The second objective of this study was to develop a multivariate model capable of predicting an expected movement pattern for an individual. The kinematic shape of the lower thoracic and lumbar spine was recorded during a constrained dynamic trunk flexion movement; as this is not a normal everyday movement task, movements are considered ‘typical’ and ‘atypical’ for this task rather than ‘normal’ and ‘abnormal’. Variations in neutral standing posture accounted for 85% of the variation in spine motion throughout the task. Differences in total spine range of flexion and a regional re-weighting of range of motion between lower thoracic and lumbar regions explained a further 9% of the variance among individuals. The analysis also highlighted a difference in temporal sequencing of motion between lower thoracic and lumbar regions which explained 2% of the total movement variation. These identified sources of variation were used to select independent variables for a multivariate linear model capable of predicting an individuals’ expected movement pattern. This was done as a proof-of-concept to demonstrate how the error between predicted and observed motion patterns could be used to differentiate between ‘typical’ and ‘atypical’ movement strategies.
Lumbar axial rotation kinematics in men with non-specific chronic low back pain
2019, Clinical Biomechanics
Lumbar flexion, coupled with rotation, is a dominant factor in the etiology and exacerbation of low back pain. Yet, no study has examined its kinematics in patients with non-specific chronic low back pain (NSCLBP). The aim of the study was to evaluate the lumbar rotation kinematics in neutral standing and with full flexion in men with NSCLBP.
ROM, average velocity, maximum velocity and maximal acceleration of lumbar rotation in neutral standing and with full flexion were measured using an industrial lumbar motion monitor in 50 men (25 with NSCLBP and 25 controls). VAS and Rolland Morris questionnaire were also included.
All examined kinematical parameters were significantly lower in men with NSCLBP compared with controls (↓ROM = 29%–45%; ↓AV = 40%–68%; ↓MV = 25%–50%; ↓MA = 20%–37%). Left rotation manifested smaller kinematic values (except for MA) than right rotation (Δ ROM = 35%; Δ AV = 66%; Δ MV = 19%) in NSCLBP. Most kinematical parameters significantly decreased from neutral standing to standing with flexion (right rotation: ↓ROM = 43%–45%, ↓AV = 38%–45%, ↓MV = 24%–27%, ↓MA for the NSCLBP group = 21%; left rotation: ↓ROM = 25%–38%, ↓AV in the control group: =34%, ↓MV in the control group: =23%, ↓MA in the control group = 25%). No correlations were found between all measured kinematical parameters, VAS and RMQ total score in the NSCLBP group.
The kinematic parameters of lumbar rotation were reduced in men with NSCLBP compared with controls both in neutral standing and with fully forward bending.
Most lumbar rotation kinematics decreased from neutral standing to standing with flexion.
Is there evidence to use kinematic/kinetic measures clinically in low back pain patients? A systematic review
2018, Clinical Biomechanics
Currently, there is a widespread reliance on self-reported questionnaires to assess low back pain patients. However, it has been suggested that objective measures of low back pain patients' functional status should be used to aid clinical assessment. The aim of this study is to systematically review which kinematic /kinetic parameters have been used to assess low back pain patients against healthy controls and to propose clinical kinematic/kinetic measures.
PubMed, Embase and Scopus databases were searched for relevant studies. Reference lists of selected studies and hand searches were performed. Studies had to compare people with and without non-specific low back pain while performing functional tasks and report body segment/joint kinematic and/or kinetic data. Two reviewers independently identified relevant papers.
Sixty-two studies were included. Common biases identified were lack of assessor blinding and sample size calculation, use of samples of convenience, and poor experimental protocol standardization. Studies had small sample sizes. Range of motion maneuvers were the main task performed (33/62). Kinematic/kinetic data of different individual or combination of body segments/joints were reported among the studies, commonest was to assess the hip joint and lumbar segment motion (13/62). Only one study described full body movement. The most commonly reported outcome was range of motion. Statistically significant differences between controls and low back pain groups were reported for different outcomes among the studies. Moreover, when the same outcome was reported disagreements were noted.
The literature to date offers limited and inconsistent evidence of kinematic/kinetic measures in low back pain patients that could be used clinically.
The distribution of lumbar intervertebral angles in upright standing and extension is related to low back pain developed during standing
2017, Clinical Biomechanics
Citation Excerpt :
Other inconclusive studies regarding LBP and lumbar curvature characteristics may not have selected the appropriate pose for capturing images or had relatively heterogeneous LBP groups (Murrie et al., 2003; Youdas et al., 2000). This pose-specificity may also explain why lumbar spine range of motion measurements from this study and others has been unsuccessful at identifying LBP patients (Lehman, 2004; Parks et al., 2003). This highlights the need for future work to focus on tasks relevant to pain generating mechanisms in studying LBP.
Lumbar lordosis measures are poorly related to clinical low back pain, however using a controlled exposure such as prolonged standing to identify pain groups may clarify this relationship. The purpose of this study was to determine the distribution of lumbar intervertebral angles in asymptomatic persons who do (pain developers) and do not (non-pain developers) develop low back pain during standing.
Sagittal plane lumbar spine radiographs of eight pain developers and eight non-pain developers were taken in three poses: upright standing, full extension and full flexion. Measures of vertebral end plate orientations from L1 to S1 were taken in each pose to compute: intervertebral angles, contribution of each level to the total curve, total lordosis, ranges of motion, relative pose positioning within the range of motion, vertebral shape, and lumbar spine recurve. Measures were compared between pain groups and lumbar levels.
Pain group differences in intervertebral angles and level contributions were greatest in the full extension pose, with pain developers having greater contributions from higher lumbar levels and fewer contributions from lower levels than non-pain developers. Pain group differences in intervertebral angle distributions were less pronounced in upright standing and non-existent in full flexion. No other measures differentiated pain groups.
Although participants had similar gross-lumbar spine curvature characteristics, non-pain developers have more curvature at lower levels in upright standing and full extension. These differences in regional vertebral kinematics may partially be responsible for standing-induced low back pain.
Multi-segmental thoracic spine kinematics measured dynamically in the young and elderly during flexion
2017, Human Movement Science
In contrast to the cervical and lumbar region, the normal kinematics of the thoracic spine have not been thoroughly investigated. The aim of this study was to characterize normal multi-segmental continuous motion of the whole thoracolumbar spine, during a flexion maneuver, in young and elderly subjects. Forty-two healthy volunteers were analyzed: 21 young (age = 27.00 ± 3.96) and 21 elderly (age = 70.1 ± 3.85). Spinal motion was recorded with a motion-capture system and analyzed using a 3rd order polynomial function to approximate spinal curvature throughout the motion sequence. The average motion profiles of the two age groups were characterized. Flexion timing of the thoracic region of the spine, as compared to the lumbar spine and hips, was found to be different in the two age groups (p = 0.011): a delayed/sequential motion type was observed in most of the young, whereas mostly a simultaneous motion pattern was observed in the elderly subjects. A similar trend was observed in flexion of the lower thoracic segments (p = 0.017). Differences between age groups were also found for regional and segmental displacements and velocities. The reported characterization of the thoracic spine kinematics may in the future support identification of abnormal movement or be used to improve biomechanical models of the spine.

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Original articleBiomechanical assessments of lumbar spinal function. how low back pain sufferers differ from normals. implications for outcome measures research. part i: kinematic assessments of lumbar function

Abstract

Objective

Data sources

Results

Conclusion

Introduction

Section snippets

Kinematic measures of lumbar function

Conclusion

Arch Phys Med Rehabil

Man Ther

Clin Biomech (Bristol, Avon)

Gait Posture

Arch Phys Med Rehabil

A new approach to the low-back physical examination. Behavioral assessment of mechanical signs

Spine

Analysis of the convergent and discriminant validity of published lumbar flexion, extension, and lateral flexion scores

Spine

Comparison of spinal mobility and isometric trunk extensor forces with electromyographic spectral analysis in identifying low back pain

Phys Ther

The quantification of low back disorder using motion measures. Methodology and validation

Spine

Lumbar spine range of motion as a measure of physical and functional impairmentan investigation of validity

Clin Rehabil

Association between measures of spinal mobility and low back pain. An analysis of new attenders in primary care

Spine

Lumbar-hip flexion motion. A comparative study between asymptomatic and chronic low back pain in 18- to 36-year-old men

Spine

The relationship of lumbar flexion to disability in patients with low back pain

Phys Ther

The classification of anatomic- and symptom-based low back disorders using motion measure models

Spine

Longitudinal quantitative measures of the natural course of low back pain recovery

Spine

Classification of low back pain from dynamic motion characteristics using an artificial neural network

Spine

Range of motion and motion patterns in patients with low back pain before and after rehabilitation

Spine

Original article
Biomechanical assessments of lumbar spinal function. how low back pain sufferers differ from normals. implications for outcome measures research. part i: kinematic assessments of lumbar function