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Corresponding author at: Department of Surgery and Cancer, Imperial College London, Room 7L16, Floor 7, Laboratory Block, Charing Cross Hospital, London, W6 8RF, UK.
Current low back pain assessment relies on subjective measures.
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Use of objective measures (kinematics/kinetics) is encouraged in low back pain assessment.
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This review highlights the heterogeneity of studies with low back pain and healthy subjects.
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There is poor evidence for kinematic/kinetic parameters as low back pain objective measures.
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Functional tasks, whole body and not only range of motion should be considered.
Abstract
Background
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.
Methods
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.
Findings
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.
Interpretation
The literature to date offers limited and inconsistent evidence of kinematic/kinetic measures in low back pain patients that could be used clinically.
Treatment for low back pain (LBP) aims to restore normal movement function and relieve pain. Measurements of movement function and measures of pain reduction, should, therefore, be the focus of LBP evaluation (
). This review is focused on measures of movement function. Movement analysis, allowing quantification of human movement, provides a means to objectify impairments from which clinical decisions can be made (
). However, clinical assessment of LBP relies predominately on self-reported questionnaires and scores, which depend on the patients' perception of their pain and functional capacity (
Measures of function in low back pain/disorders: low back pain rating scale (LBPRS), Oswestry disability index (ODI), progressive Isoinertial lifting evaluation (PILE), Quebec back pain disability scale (QBPDS), and Roland-Morris disability questionnaire (RDQ).
). This relates to the multifactorial and complex nature of LBP. Psychosocial factors, such as fear avoidance, dissatisfaction at work and pain beliefs as well as mechanical factors due to daily movement contribute to LBP development and occurrence (
). The interaction among these factors makes non-specific LBP difficult to classify and leaves clinicians facing significant challenges during its evaluation and management with consequences on patients' recovery. Imaging techniques, such as X-rays, computed tomography and magnetic resonance imaging, are employed in clinical practice but do not increase clinicians' ability to assess function and provide few if any indicators on how to manage non-specific LBP (
). Conversely, the ability to objectively assess the extent of movement impairments due to LBP has the potential to aid clinical assessment and, combined with psychosocial intervention, may provide important treatment targets.
The use of objective measures of LBP patients' movement function, alongside self-reported questionnaires, has been recently encouraged (
Measures of function in low back pain/disorders: low back pain rating scale (LBPRS), Oswestry disability index (ODI), progressive Isoinertial lifting evaluation (PILE), Quebec back pain disability scale (QBPDS), and Roland-Morris disability questionnaire (RDQ).
), yet definition of functional motion and what should be measured is lacking. Lumbar range of motion (RoM) is frequently used in the clinical diagnosis of LBP despite its known variability and its questionable ability to discriminate between controls and LBP patients (
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.
). Failure in differentiating these two groups on the basis of movement function is further aggravated by not considering the existence of sub-groups of LBP patients based on adopted movement strategies to accomplish a task. Moreover, it has been recently suggested that assessment should not be limited to the spine but should consider the spine in a whole-body context, including the lower limbs (
Three-dimensional kinematic analysis of pelvic and lower extremity differences during trunk rotation in subjects with and without chronic low back pain.
). The lower limbs interfacing with externally applied forces may play an important role in spinal function during movement and standing as these are part of the body's kinematic chain. However, to date the full role of lower limb mechanics in the development and persistence of LBP is not known (
Three-dimensional kinematic analysis of pelvic and lower extremity differences during trunk rotation in subjects with and without chronic low back pain.
). Since both the upper and lower body systems are active segments responsible for the achievement of everyday motor tasks none of them should be omitted in functional assessments.
For this paper, we focus on objective measures of LBP movement function that could empirically, by appropriate techniques, highlight significant differences between control and LBP populations thus providing a greater understanding of LBP biomechanical mechanisms to refine assessments and treatment options. This is to go beyond the subjectivity of self-reported questionnaires and observational clinical assessment. The aim of this systematic review was to evaluate the available literature in relation to kinematic and kinetic parameters that have been used to assess LBP patients' movement function compared to healthy controls and to identify possible objective measures of LBP, based on the parameters reported in published studies, which could be used clinically to aid LBP assessment and management. The research questions we sought to address were: i) Can kinematic/kinetic data differentiate between LBP patients and control subjects? ii) Which measurements and methods have been used to characterise patterns of motion that might be relevant to LBP? iii) Can such methods be translated to the clinical environment?
2. Methods
This systematic review was conducted in accordance with the PRISMA Statement (
Studies were included in the review if they: 1) included adults over 18 years old, 2) were published in English, 3) considered patients presenting with non-specific LBP only, 4) included data from a healthy control group or healthy database, 5) used joint/body segment kinematic and/or kinetic data as an outcome measure, 6) considered active movements, 7) included appropriate statistical reporting, and 8) were peer-reviewed. Studies were excluded if they: 1) were a case-study design, 2) included subjects with specific LBP caused by pathological entities and attributable to a recognisable pathology (e.g., scoliosis, spinal stenosis, disc herniation, ankylosing spondylitis, cauda equina, tumour, osteoporosis, fracture), 3) reported only imaging or muscle data, and 4) described patients as having back pain with no specific reference made to LBP.
2.2 Data sources and search strategy
Electronic databases, PubMed, Embase and Scopus, were searched from the earliest records up until May 2016. The search strategy combined three conceptual groups of terms: LBP, Testing Procedure/Method, and Measurement/Outcome. Controlled vocabulary terms (e.g. Mesh terms) and key words were used. PubMed search strategy, from which other database searches were derived, is reported in Supplementary File 1. Citation tracking of selected studies and hand searches were also performed to identify additional relevant articles missed by the electronic searches. Searched articles were imported into EndNote ×7 software (Thomson, Reuters, Carlsbad, CA) for subsequent study selection.
2.3 Review process
Two independent reviewers (EP, AM) screened titles and abstracts to identify eligible studies. Full text articles were assessed for eligibility criteria by EP and AM independently. Disagreements were resolved by consensus discussions.
Table 1Quality assessment summary.
Quality assessment domains
% of studies scoring yes
Study population bias
1
Was the study population adequately described?
85%
2
Were both groups drawn from the same population?
16%
3
Were both groups comparable for age, sex, BMI/weight?
72%
4
Were the subjects asked to participate in the study representative of the entire population from which they were recruited?
0%
5
Was pain intensity and/or activity limitation described for LBP group?
72%
6
Was an attempt made to define back pain characteristics?
92%
7
Were the eligibility criteria specified?
89%
Measurement and outcome bias
8
Did the method description enable accurate replication of the measurement procedures?
98%
9
Was the measurement equipment adequately described?
100%
10
Was a system for standardizing movement instructions reported?
42%
11
Were assessors trained in standardized measurement procedure?
8%
12
Did the same assessors test those with and without back pain?
11%
13
Were assessors blinded as to which group subjects were in?
2%
14
Was assessment procedure applied to those with and without back pain the same?
100%
15
Were the main outcomes to be measured and the related calculations (if applicable) clearly described?
97%
16
Were the main outcome measures used accurate (valid and reliable)?
97%
Data presentation bias
17
Are the main findings of the study clearly described?
97%
18
Were the statistical tests appropriate?
98%
19
The results of between-group statistical comparisons were reported for at least one key outcome
95%
20
Have actual probability values been reported (e.g. 0.035 rather than <0.05) for the main outcomes except where the probability value is <0.001?
53%
21
Point estimates and measures of variability were provided for at least one key outcome for those with and without back pain
92%
22
Did the study have sufficient power to detect a clinically important effect where the probability value for a difference being due to chance is <5%?
10%
23
Was the reliability and/or validity of the outcomes commented upon?
The following study details were extracted from each included study, using a customised data extraction form: study aims, design, sample size, participant demographics, task conducted, equipment used, body segments analysed, kinematic and kinetic variables evaluated, statistical analysis technique, statistically significant outcomes. As no standardized or validated quality checklists exist for this type of review, a customised quality assessment tool was constructed based on tools used in similar studies (
The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions.
) to determine sources of bias in the selected articles. The quality assessment tool used was divided into three domains: study population bias, measurement and outcome bias, and data presentation bias (Table 1). Population description, experimental methodology and reporting of the results could, thus, be evaluated. Ratcliffe et al.'s rating score was used to rate the quality of the reviewed paper: studies scored as high quality achieve a score >66.8%, medium quality 33.4–66.7%, and low quality <33.3%. (
). Assessment checklist questions and the correspondent decision rules are available in Supplementary File 2.
3. Results
3.1 Study selection
The study selection process is shown in Fig. 1. The initial search yielded 13,211 articles, with duplicates removed, with 6 additional articles identified through citation tracking and hand searches. After screening titles and abstracts, 13,104 articles were excluded as they were deemed irrelevant to this review topic. Inclusion criteria were applied to the full-texts of 110 articles. Of these, 62 met the inclusion criteria; reasons for exclusion of the other 48 articles are shown in Fig. 1. A meta-analysis of the study results was not appropriate as this review did not examine clinical interventions and also because of the diverse methodological approaches adopted. A summary of included studies is available in Supplementary File 3.
Comparison of spinal range of motion during flexion-extension using a three-dimensional opto-electronic system in healthy volunteers and patients with chronic low back pain.
Quantitative assessment of the motion of the lumbar spine in the low back pain population and the effect of different spinal pathologies of this motion.
Spinal kinematics and trunk muscle activity in cyclists: a comparison between healthy controls and non-specific chronic low back pain subjects-a pilot investigation.
Three-dimensional kinematic analysis of pelvic and lower extremity differences during trunk rotation in subjects with and without chronic low back pain.
Effects of pelvic skeletal asymmetry on trunk movement: three-dimensional analysis in healthy individuals versus patients with mechanical low back pain.
Assessment of combined movements of the lumbar spine in asymptomatic and low back pain subjects using a three-dimensional electromagnetic tracking system.
Interexaminer reliability and discriminant validity of inclinometric measurement of lumbar rotation in chronic low-back pain patients and subjects without low-back pain.
Comparison of spinal range of motion during flexion-extension using a three-dimensional opto-electronic system in healthy volunteers and patients with chronic low back pain.
Quantitative assessment of the motion of the lumbar spine in the low back pain population and the effect of different spinal pathologies of this motion.
Spinal kinematics and trunk muscle activity in cyclists: a comparison between healthy controls and non-specific chronic low back pain subjects-a pilot investigation.
Three-dimensional kinematic analysis of pelvic and lower extremity differences during trunk rotation in subjects with and without chronic low back pain.
Comparing lower lumbar kinematics in cyclists with low back pain (flexion pattern) versus asymptomatic controls - field study using a wireless posture monitoring system.
Interexaminer reliability and discriminant validity of inclinometric measurement of lumbar rotation in chronic low-back pain patients and subjects without low-back pain.
Assessment of combined movements of the lumbar spine in asymptomatic and low back pain subjects using a three-dimensional electromagnetic tracking system.
Interexaminer reliability and discriminant validity of inclinometric measurement of lumbar rotation in chronic low-back pain patients and subjects without low-back pain.
Effects of pelvic skeletal asymmetry on trunk movement: three-dimensional analysis in healthy individuals versus patients with mechanical low back pain.
Assessment of combined movements of the lumbar spine in asymptomatic and low back pain subjects using a three-dimensional electromagnetic tracking system.
Interexaminer reliability and discriminant validity of inclinometric measurement of lumbar rotation in chronic low-back pain patients and subjects without low-back pain.
Spinal kinematics and trunk muscle activity in cyclists: a comparison between healthy controls and non-specific chronic low back pain subjects-a pilot investigation.
Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model.
Comparison of the lumbar flexion angle and repositioning error during lumbar flexion-extension in young computer workers in Korea with differing back pain.
The effect of load on the coordination of the trunk for subjects with and without chronic low back pain during flexion-extension and lateral bending tasks.
Three-dimensional kinematic analysis of pelvic and lower extremity differences during trunk rotation in subjects with and without chronic low back pain.
A compensation of angular displacements of the hip joints and lumbosacral spine between subjects with and without idiopathic low back pain during squatting.
Effects of pelvic skeletal asymmetry on trunk movement: three-dimensional analysis in healthy individuals versus patients with mechanical low back pain.
Spinal kinematics and trunk muscle activity in cyclists: a comparison between healthy controls and non-specific chronic low back pain subjects-a pilot investigation.
Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model.
Comparison of the lumbar flexion angle and repositioning error during lumbar flexion-extension in young computer workers in Korea with differing back pain.
Three-dimensional kinematic analysis of pelvic and lower extremity differences during trunk rotation in subjects with and without chronic low back pain.
A compensation of angular displacements of the hip joints and lumbosacral spine between subjects with and without idiopathic low back pain during squatting.
Comparing lower lumbar kinematics in cyclists with low back pain (flexion pattern) versus asymptomatic controls - field study using a wireless posture monitoring system.
Interexaminer reliability and discriminant validity of inclinometric measurement of lumbar rotation in chronic low-back pain patients and subjects without low-back pain.
Comparison of spinal range of motion during flexion-extension using a three-dimensional opto-electronic system in healthy volunteers and patients with chronic low back pain.
Comparison of the lumbar flexion angle and repositioning error during lumbar flexion-extension in young computer workers in Korea with differing back pain.
The effect of load on the coordination of the trunk for subjects with and without chronic low back pain during flexion-extension and lateral bending tasks.
Three-dimensional kinematic analysis of pelvic and lower extremity differences during trunk rotation in subjects with and without chronic low back pain.
A compensation of angular displacements of the hip joints and lumbosacral spine between subjects with and without idiopathic low back pain during squatting.
Spinal kinematics and trunk muscle activity in cyclists: a comparison between healthy controls and non-specific chronic low back pain subjects-a pilot investigation.
Comparing lower lumbar kinematics in cyclists with low back pain (flexion pattern) versus asymptomatic controls - field study using a wireless posture monitoring system.
Fig. 2(a) Overall sample size, (b) participants mean age (top) and age variability expressed as standard deviation (SD) per number of selected articles. In brackets corresponding % of articles is shown.
Interexaminer reliability and discriminant validity of inclinometric measurement of lumbar rotation in chronic low-back pain patients and subjects without low-back pain.
Spinal kinematics and trunk muscle activity in cyclists: a comparison between healthy controls and non-specific chronic low back pain subjects-a pilot investigation.
Comparison of spinal range of motion during flexion-extension using a three-dimensional opto-electronic system in healthy volunteers and patients with chronic low back pain.
Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model.
The effect of load on the coordination of the trunk for subjects with and without chronic low back pain during flexion-extension and lateral bending tasks.
A compensation of angular displacements of the hip joints and lumbosacral spine between subjects with and without idiopathic low back pain during squatting.
Comparing lower lumbar kinematics in cyclists with low back pain (flexion pattern) versus asymptomatic controls - field study using a wireless posture monitoring system.
Three-dimensional kinematic analysis of pelvic and lower extremity differences during trunk rotation in subjects with and without chronic low back pain.
Effects of pelvic skeletal asymmetry on trunk movement: three-dimensional analysis in healthy individuals versus patients with mechanical low back pain.
Assessment of combined movements of the lumbar spine in asymptomatic and low back pain subjects using a three-dimensional electromagnetic tracking system.
Comparison of the lumbar flexion angle and repositioning error during lumbar flexion-extension in young computer workers in Korea with differing back pain.
Quantitative assessment of the motion of the lumbar spine in the low back pain population and the effect of different spinal pathologies of this motion.
). Moreover, LBP duration was often lacking and large durations in symptoms were reported (ranging from 3 months to 5 years within one study). The level of pain/disability, if described (43/62), was low to moderate (
Spinal kinematics and trunk muscle activity in cyclists: a comparison between healthy controls and non-specific chronic low back pain subjects-a pilot investigation.
Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model.
Comparison of the lumbar flexion angle and repositioning error during lumbar flexion-extension in young computer workers in Korea with differing back pain.
Three-dimensional kinematic analysis of pelvic and lower extremity differences during trunk rotation in subjects with and without chronic low back pain.
A compensation of angular displacements of the hip joints and lumbosacral spine between subjects with and without idiopathic low back pain during squatting.
Comparing lower lumbar kinematics in cyclists with low back pain (flexion pattern) versus asymptomatic controls - field study using a wireless posture monitoring system.
Most studies demonstrated an age bias with most participants recruited being in their thirties (Fig. 2b). It is however worth noticing the age variability within groups, in 45 studies age standard deviation values were above 7 years (
Effects of pelvic skeletal asymmetry on trunk movement: three-dimensional analysis in healthy individuals versus patients with mechanical low back pain.
Assessment of combined movements of the lumbar spine in asymptomatic and low back pain subjects using a three-dimensional electromagnetic tracking system.
Comparison of spinal range of motion during flexion-extension using a three-dimensional opto-electronic system in healthy volunteers and patients with chronic low back pain.
Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model.
Quantitative assessment of the motion of the lumbar spine in the low back pain population and the effect of different spinal pathologies of this motion.
Three-dimensional kinematic analysis of pelvic and lower extremity differences during trunk rotation in subjects with and without chronic low back pain.
A compensation of angular displacements of the hip joints and lumbosacral spine between subjects with and without idiopathic low back pain during squatting.
Comparing lower lumbar kinematics in cyclists with low back pain (flexion pattern) versus asymptomatic controls - field study using a wireless posture monitoring system.
Effects of pelvic skeletal asymmetry on trunk movement: three-dimensional analysis in healthy individuals versus patients with mechanical low back pain.
Assessment of combined movements of the lumbar spine in asymptomatic and low back pain subjects using a three-dimensional electromagnetic tracking system.
Interexaminer reliability and discriminant validity of inclinometric measurement of lumbar rotation in chronic low-back pain patients and subjects without low-back pain.
Comparison of spinal range of motion during flexion-extension using a three-dimensional opto-electronic system in healthy volunteers and patients with chronic low back pain.
Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model.
Comparison of the lumbar flexion angle and repositioning error during lumbar flexion-extension in young computer workers in Korea with differing back pain.
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