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Low back pain influences trunk-lower limb joint coordination and balance control during standing in persons with lower limb loss

  • Courtney M. Butowicz
    Correspondence
    Corresponding author at: 4494 N. Palmer Road, America Building, Room B312, Bethesda, MD 20889, USA.
    Affiliations
    Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
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  • Adam J. Yoder
    Affiliations
    Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, Naval Medical Center, San Diego, CA, USA
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  • Shawn Farrokhi
    Affiliations
    Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, Naval Medical Center, San Diego, CA, USA

    Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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  • Brittney Mazzone
    Affiliations
    Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, Naval Medical Center, San Diego, CA, USA

    Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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  • Brad D. Hendershot
    Affiliations
    Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA

    Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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      Highlights

      • Low back pain alters trunk-lower limb coordination in persons with lower limb loss.
      • Trunk-hip coordination predicts center of mass variability during standing balance.
      • Opposing trunk-hip coordination may illustrate a mechanism for back pain recurrence.

      Abstract

      Background

      Balance is sustained through multi-joint coordination in response to postural perturbations. Low back pain alters postural responses; however, it is unknown how coordination between the trunk and lower extremities affects center of mass control during standing balance among persons with limb loss, particularly those with back pain.

      Methods

      Forty participants with unilateral lower limb loss (23 with back pain) stood with eyes open and closed on a firm surface, while wearing IMUs on the sternum, pelvis, and bilaterally on the thigh, shank, and foot. A state-space model with Kalman filter calculated sagittal trunk, hip, knee, and ankle joint angles. Fuzzy entropy quantified center of mass variability of sagittal angular velocity at the sacrum. Normalized cross-correlation functions identified coordination patterns (trunk-hip, trunk-knee, trunk-ankle). Multiple linear regression predicted fuzzy entropy from cross-correlation values for each pattern, with body mass and amputation level as covariates.

      Findings

      With eyes open, trunk-lower limb joint coordination on either limb did not predict fuzzy entropy. With eyes closed, positive trunk-hip coordination on the intact limb predicted fuzzy entropy in the pain group (p = 0.02), but not the no pain group. On the prosthetic side, inverse trunk-hip coordination patterns predicted fuzzy entropy in pain group (p = 0.03) only.

      Interpretation

      Persons with limb loss and back pain demonstrated opposing coordination strategies between the lower limbs and trunk when vision was removed, perhaps identifying a mechanism for pain recurrence. Vision is the dominant source of balance stabilization in this population, which may increase fall risk when visual feedback is compromised.

      Keywords

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