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Journal of Back and Musculoskeletal Rehabilitation 00 (2014) 1–14 DOI 10.3233/BMR-140533 IOS Press
Review Article
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Methods for the assessment of neuromotor capacity in non-specific low back pain: Validity and applicability in everyday clinical practice
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Jorge Hugo Villafañea,∗, Luca Zanettib , Maria Isgròa , Joshua A. Clelandc,d , Lucia Bertozzie , Massimiliano Gobbof and Stefano Negrinia,f a
IRCCS Don Gnocchi Foundation, Milan, Italy School of Physiotherapy, University of Brescia, Italy c Department of Physical Therapy, Franklin Pierce University, Concord, NH, USA d Physical Therapist, Rehabilitation Services, Concord Hospital, NH, USA e School of Physical Therapy, Alma Mater Studiorum, University of Bologna, Bologna, Italy f Department of Clinical and Experimental Sciences, University of Brescia, Italy
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Abstract. BACKGROUND: Physiotherapists and clinicians require methods that can be used in everyday practice for measuring proprioception of the trunk in individuals with non-specific low back pain (NSLBP). OBJECTIVE: Our objective was to conduct a systematic literature review of methods used for assessment of proprioception of the trunk in individuals with non-specific low back pain METHOD: Data were obtained from MEDLINE, CINAHL, Embase, PEDro and CENTRAL databases from their inception to December 2011. Reference lists of the selected reviews were hand searched for other potentially relevant studies. Randomized and nonrandomized controlled studies proprioception of the trunk in individuals with low back pain were selected. Thirty-six studies satisfied the selection criteria and were included in this review. RESULTS: Two reviewers independently selected the studies, conducted the quality assessment, and extracted data from each study. The Strobe scale was used to evaluate the scientific rigor of each selected study. CONCLUSIONS: This systematic review covered all the relevant literature, but none of the included studies offered a valid, reliable and feasible method to assess the neuromotor capacity in everyday physiotherapy clinical practice. Keywords: Non-specific low back pain, low back pain, proprioception, motor control, equilibrium, balance, kinesthesia, repositioning error, clinical applicability
∗ Corresponding
author: Jorge Hugo Villafañe, Regione Generala 11/16, Piossasco (10045), Turin. Italy. Tel.: +39 3395857563; E-mail: [email protected].
1. Introduction
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Non-specific low back pain (NSLBP) is the most common musculoskeletal disorder affecting about 84% of the population, with a prevalence of 23% of individuals suffering from chronic non-specific low back pain
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c 2014 – IOS Press and the authors. All rights reserved ISSN 1053-8127/14/$27.50
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2.2. Study selection
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Several criteria were used to select eligible studies. Articles were included if the study design was a clinical trial and were written in English, German, or Italian. We included randomized and non-randomized controlled studies with no restriction of subjects age, which considered patients with NSLBP only. Articles were excluded if: (1) the study had an inappropriate design (i.e., not a clinical trial such as observational studies); (2) subjects had specific low back pain (i.e., structural deformities of the trunk like scoliosis, fractures, spondylolysis, spondylolisthesis, any surgery, symptomatic lumbar disc herniations, radicular symptoms, cauda equina syndrome, rheumatologic diseases, osteoporosis, infections, cancer); (3) subjects had vestibular diseases or conditions that cause a specific balance impairment; (4) patients were diagnosed for acute low back pain (considered here < 30 days); (5) patients underwent electromyographic evaluation of the stabilizing ability of the trunk (in that this type of kinesiological analysis was not considered as feasible in everyday clinical practice).
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2.3. Data extraction and quality assessment
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The literature search, data extraction, and quality assessment procedures were performed by two independent researchers (L. Z. and M.G.). Score discrepancies were rare and any discrepancies were resolved by consensus. The titles and abstracts of the selected articles generated by the search strategy were first screened to eliminate irrelevant articles. The full text of each of the remaining articles was then reviewed to determine eligibility. Eventually, the scientific rigor of the eligible studies was assessed with a modified Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [10] scale. Among the 22 items of the scale, we excluded the items referring to the title, introduction and discussion (7 elements) as we aimed at focussing exclusively on the quality of methods and results of the studies (Table 1). We used a modified version of STROBE scale since a valid, reliable and universally accepted scale for the assessment of the methodological quality of physical therapy trials still needs to be developed [11]. To note that STROBE
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gibility criteria. A forward search with the Science Citation Index was conducted to identify and examine all subsequent articles that referenced the selected articles.
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(CNSLBP) [1]. Although the natural history of this condition appears to be favorable, the rate of chronicity is thought to represent the most prevalent and costly health problem in world [2]. In an attempt to reduce the social impact of NSLBP individuals often present to physical therapy [3]. A comprehensive examination is necessary for subgrouping and to determine appropriate interventions for this patient population [1]. Despite subgrouping, physiotherapists typically do not treat all the deficits associated with NSLBP such as, for instance, proprioception [4,5]. Proprioception is defined as the complex interaction between afferent and efferent inputs to control body movement and posture [6]. If any of the afferent components are damaged, proprioceptive deficits may occur. Additionally, fatigue [7] and respiration [8, 9] have been recognized as factors that can potentially destabilize posture and performance in individuals with NSLBP and could have important implications in the rehabilitation process. To our knowledge no systematic reviews have been conducted in the attempt to identify the most valid and reliable methods for proprioception assessment in individuals with NSLBP that may also prove to be feasible for physiotherapists in everyday clinical practice. The objective of this systematic literature review was to examine the methods used for assessment of proprioception of the trunk in individuals with NSLBP and investigate their applicability in everyday practice to enhance physical therapy.
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The following databases were searched from 1980 to December 2011: MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, Physiotherapy Evidence Database (PEDro) and Cochrane Central Register of Controlled Trials (CENTRAL). See Quorom diagram (Fig. 1). English language-only key word searches were used with combinations of terms including “non-specific low back pain”, “low back pain”, “proprioception”, “motor control”, “equilibrium”, “balance”, “kinesthesia”, “repositioning error”. The combinations, for instance, included: low back pain AND proprioception, low back pain AND motor control, and so on. The reference list of each selected article was hand-searched to identify other potential articles that might have fulfilled the eli-
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Literature Search:: n°184 Papers rejected after abstracts screening: n°134 Full papers obtained and screened: n°50 Papers included after hand search: n°11
Papers rejected after full text reading: n°25
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Papers accepted for review after screening: n°36
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2.4. Criteria to judge clinical applicability of methods used to measure proprioception
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2.5. Data synthesis and analysis
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Kappa statistics were used to assess agreement between the two raters on article selection and Strobe ratings. The Strobe statement delineates essential items to be reported in cohorts research studies. Subsequently we selected studies for this review with a score 10.
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We are not aware of an existing operational definition of “applicability in everyday clinical practice” of specific tests. Consequently, before starting the research we defined a-priori the following set of criteria in order to determine the feasibility of performing the tests in clinical practice: – Setting where the assessment was carried out (i.e., clinic, laboratory, treatment room) – Qualification of the operator performing the test (i.e., physical therapist, physician, researcher) – Time needed for the execution of the test. Time needed to analyze the data from the tests – Instruments/devices required to perform the test – Cost of the instruments/devices – Knowledge of repeatability of measurements All selected studies where examined to determine if these criteria were present.
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3. Results
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Figure 1 shows the process of study selection. Initial searching identified 184 citations. Following the first screening, 134 articles were excluded and 50 citations were retained for the second screening. Eleven studies were retrieved through hand-searching of the references in the previously selected papers. Using the inclusion and exclusion criteria a further 25 articles were excluded. In total, 36 articles were selected for the review. See Table 2. The level of interrater reliability on article screening through reading of the titles and abstracts was excellent according to Fleiss (kappa = 0.85, 95% CI: 0.81–1.0), as was the article selection through reading of the full text of each of the remaining articles.
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3.1. Study characteristics
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The majority of authors (32/36, 89%) described the basic anthropometric characteristics of participants (sex, age, height and weight). In addition, only 14 studies (39%) reported at least two parameters among training status, health status and job. With regard to the assessment methods, the most frequently performed tests were static tests as the displacement of the center of gravity (23/36, 64%) and dynamic tests such as the ability of repositioning or the reproduction of a movement (10/36, 28%). Other assessment methods were: the analysis of the amplitude of movement (3/36, 8%), the study of the motion perception threshold (2/36, 6%) and the examination of psychomotor speed (1/36, 3%).
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scale gives particular attention to confounders which critically affect the quality and relevance of outcome data. Each item was scored a maximum of 1 point if full reporting criteria were met and 0 point if the criteria were not met, for a total possible score of 15 points.
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Fig. 1. Flowchart of papers.
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J.H. Villafañe et al. / Methods for the assessment of neuromotor capacity in non-specific low back pain Table 1 STROBE statement: Checklist of items that should be included in reports of cohort studies Item No Recommendation 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract (b) Provide in the abstract an informative and balanced summary of what was done and what was found
Title and Abstract
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Explain the scientific background and rationale for the investigation being reported State specific objectives, including any prespecified hypotheses
Methods Study design Setting
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Participants
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Variables
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Data sources/measurement
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Bias Study size Quantitative variables
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Statistical methods
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Present key elements of study design early in the paper Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection (a) Give the eligibility criteria, and the sources and methods of selection of participants. Describe methods of follow-up (b) For matched studies, give matching criteria and number of exposed and unexposed Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if applicable For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group Describe any efforts to address potential sources of bias Explain how the study size was arrived at Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why (a) Describe all statistical methods, including those used to control for confounding (b) Describe any methods used to examine subgroups and interactions (c) Explain how missing data were addressed (d) If applicable, explain how loss to follow-up was addressed (e) Describe any sensitivity analyses
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Other analyses Discussion Key results Limitations
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Interpretation
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Generalisability
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Other information Funding
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Outcome data Main results
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(a) Report numbers of individuals at each stage of study – eg numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completing follow-up, and analysed (b) Give reasons for non-participation at each stage (c) Consider use of a flow diagram (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential confounders (b) Indicate number of participants with missing data for each variable of interest (c) Summarise follow-up time (eg, average and total amount) Report numbers of outcome events or summary measures over time (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and why they were included (b) Report category boundaries when continuous variables were categorized (c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period Report other analyses done – eg analyses of subgroups and interactions, and sensitivity analyses
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Results Participants
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Introduction Background/rationale Objectives
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Summarise key results with reference to study objectives Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and magnitude of any potential bias Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from similar studies, and other relevant evidence Discuss the generalisability (external validity) of the study results
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Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based
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information separately for exposed and unexposed groups.
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Fig. 2. Graphic distribution of the studies depending on their methodological quality.
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Twenty one of the 36 studies (71%) were identified as having high methodological rigor. Figure 2 shows the graphic distribution of studies according to the scores obtained from the assessment of their methodological quality.
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3.3. Confounders
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The influence of sex, age, height, weight and pain between groups was quantified in 19/21 studies with high methodological rigor (90%), and comprehensively, in 22/36 studies (61%) overall. Other parameters considered as “confounders” were the number of trials carried out and the value of V.A.S. (Visual Analogue Scale) as a measure of pain at the time of the tests (Table 2). Unfortunately it was not possible to obtain all data from each study. A third of the articles did not present V.A.S. values as information of the extent of pain, while other three authors [8,12,13] have provided approximate values (< 2) compared to the precise scores provided by the majority of the studies; an average V.A.S. value of 1,5 has been assigned to them. Figures 3 and 4 show the distributions of the two parameters grouped in studies that have or have not found statistically significant differences in the neuromotor ability of the trunk between subjects with low back pain and healthy controls. In regards to those studies that reported two VAS values (one for men and one for women), the average value was calculated and reported here.
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3.4. Low back pain and proprioceptive deficits
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In general, the measurements reported by the studies have shown a wide variability.
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3.4.1. COP (center of pressure) displacement In comparison to healthy subjects, subjects with low back pain seem to exhibit greater postural sway: this difference was significant in most of the studies (17/36, 52%). In particular, 3 studies demonstrated that the deficit is greater in absence of visual feedback [14– 16], 5 studies have found greater COP displacements in unstable conditions or during difficult tests [15–19], while 2 studies showed the destabilizing effect of respiration on postural control [8,9]. Only one study [19], has distinguished between the center of mass and center of pressure showing different results between the two parameters. Additionally, patients with low back pain exhibited a higher COP displacement speed [15, 18,21–23]. No significant differences between cases and controls were found in 6 studies [13,23,25–28]. 3.4.2. Capacity of repositioning and of reproducing a movement The studies that investigated the neuromotor control of the spine in subjects with low back pain through the capacity to reproduce a movement have failed to result in agreement. Some studies [14,29–32], have demonstrated the existence of a reduced motor perception; conversely, other studies [4,33–36] have failed to show a statistically significant difference in the ability of repositioning between patients with NSLBP and controls.
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J.H. Villafañe et al. / Methods for the assessment of neuromotor capacity in non-specific low back pain Table 2 Studies description Studies
1. Alexander et Kinney LaPier (1998)
Setting and Study samples Assessment method health worker NA/NA 15 healthy subjects COP displacement 15 subjects with NSLBP
Equipment
Results
Balance Master, Neurocom NSLBP: increased COP displacement with and without visual feedback
31 healthy subjects Movement magnitude 3SPACE Fastrak 23 subjects with NSLBP
NSLBP: smaller movement magnitude
3. Brumagne NA/NA et al. (2008a)
33 healthy subjects – COP displacement – 2 piezo-resistive electro- – No differences between the two groups when visual feedback is goniometers – Ability to repro56 subjects with permitted duce a movement – Bertec Corporation, force NSLBP – NSLBP: greater anterior sway platform with and without a in absence of visual feedback visual feedback – NSLBP: greater anterior sway in anticipation of postural instability
4. Brumagne NA/NA et al. (2008b)
24 healthy subjects COP displacement 21 subjects with NSLBP
5. Brumagne NA/NA et al. (2000)
21 healthy subjects Repositioning accuracy 23 subjects with NSLBP
6. Brumagne NA/NA et al. (2004)
20 healthy subjects COP displacement 20 subjects with NSLBP
7. Claeys et al. NA/NA (2011)
50 healthy subjects COP displacement 106 subjects with LBP
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2. Barrett et al. NA/ (1999) Physical therapist?
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– Bertec Corporation, force – NSLBP: greater sway in instability conditions platform – NSLBP: rely more on ankle – 2 piezo-resistive proprioception to control their accelerometers posture even in conditions – 2 muscular vibrators when this strategy is not the (Maxon motors) most appropriate (unstable support surfaces) – Muscular vibrator (VB100, Dynatronic) – Piezo-resistive electrogoniometer
– NSLBP: greater repositioning error
– Bertec Corporation, force NSLBP: rely more on ankle stratplatform egy to control their posture – Muscular vibrator – Bertec Corporation, force – NSLBP: rely more on ankle platform proprioception to control their – 2 piezo-resistive posture and have a reduced caaccelerometers pacity to switch postural con(ICSensors) trol strategy
8. Della Volpe NA/NA et al. (2006)
12 healthy subjects COP displacement 12 subjects with NSLBP
Equitest, Neurocom Int. Inc, platform
– No significant differences between the 2 groups in the COP displacement in stable conditions – NSLBP: greater sagittal sway in unstable conditions
9. Descarreaux NA/NA et al. (2005)
15 healthy subjects Repositioning accuracy 7 subjects with mild NSLBP 9 subjects with severe NSLBP
Loredan Biomedical
– NSLBP: when given a learning period, they were able to reproduce trunk position with a spatial accuracy similar to healthy subjects, even if they changed some spatial and temporal parameters
10. Georgy (2011)
15 healthy subjects COP displacement 15 subjects with NSLBP 15 subjects with discogenic LBP
Biodex System 3 Pro Isokinetic Dynamometer
– SLBP: greater repositioning error
NA/NA
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Table 2, continued Studies
Setting and health worker NA/ Physical Therapist
Study samples
Assessment method
Equipment
Results – A significative difference exists in proprioception between subjects with low back pain and healthy subjects
12. Grimstone et NA/NA Hodges (2003)
10 healthy subjects Effect of respiration – Kistler, force platform – 6 sensors (Motionstar on postural control 10 subjects with movement analysis NSLBP system, ascension technology) – Respitrace 200, plethysmograph
NSLBP: respiration is a factor that destabilizes posture
13. Hamaoui NA/NA et al. (2004)
10 healthy subjects – COP displacement Bertec Corporation, force – Movement magni- platform 10 subjects with tude NSLBP
NSLBP: postural sway increase is not related to reduced spine range of motion
14. Hamaoui NA/NA et al. (2002)
10 healthy subjects Effect of respiration on postural control 10 subjects with NSLBP
– Bertec Corporation, force NSLBP: respiration is a factor that destabilizes posture platform – Respiration sensor
15. Harringe NA/NA et al. (2008)
18 healthy subjects COP displacement 11 subjects with NSLBP 17 lower extremities injury subjects 11 multiple injury subjects
AMTI, force platform
16. Henry et al. (2006)
24 healthy subjects COM and COP dis- – 3 infrared camera system, – NSLBP: reduced and delayed sagittal plane COP responses BTS placement 26 subjects with – NSLBP: the sagittal plane COP – AMTI, force platform NSLBP responses were larger in magnitude and delayed in onset.
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The method used to determine the proprioceptive deficit could not discriminate between individuals with and without NSLBP
12 healthy subjects COP displacement 12 subjects with NSLBP
– OR6-2000 AMTI, force platform
– NSLBP: less postural changes in the sagittal plane, during prolonged standing – NSLBP: increased sways in static trials
3Space Fastrak
– NSLBP: repositioning accuracy similar to performances of healthy subjects of another study – NSLBP: overshot the neutral position more frequently than healthy individuals
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18 healthy subjects Abilty to reproduce a Lumbar Motion Monitor (LMM) 62 subjects with given position NSLBP
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17. Koumantakis NA/NA et al. (2002)
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NSLBP: increased COP displacement in unstable conditions and without visual feedback than lower extremities injury subjects
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20 healthy subjects Abilty to reproduce a Lumbar Motion Monitor given position (LMM) 20 subjects with NSLBP
11. Gill et Callaghan (1998)
19. Lam et al. (1999)
NA/NA
20 subjects with NSLBP
Repositioning accuracy
20. Lee et al. (2010)
University laboratory/NA
24 healthy subjects – Movement percep- Flock of Birds, Ascension tion threshold Technology Corp 24 subjects with – Repositioning NSLBP accuracy
– SLBP: greater movement perception threshold – No significant differences between healthy and low back pain sufferers in the repositioning tests – NSLBP: more errors in the passive repositioning tests than in the active
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J.H. Villafañe et al. / Methods for the assessment of neuromotor capacity in non-specific low back pain Table 2, continued Studies
21. Luoto et al. (1996)
Setting and health worker Undisturbed room/3 Physical therapists
Study samples
Assessment method
Equipment
Results
61 healthy subjects – Psycomotor speed Vertical force platform – COP displacement 68 subjects with mild NSLBP 31 subjects with severe NSLBP
– NSLBP: slower reaction times – NSLBP (women): worse postural control than healthy women
– NSLBP: greater postural instability – No significant differences between subjects with NSLBP and healthy controls in the sagittal displacement of COP in unstable conditions – NSLBP affects the one-footed postural control by increasing the speed of COP displacements
NA/3 Physical therapists
61 healthy subjects – COP displacement – Vertical force platform (also one-footed) – Muscular stimulators 68 subjects with mild NSLBP 31 subjects with severe NSLBP
23. Mann et al. (2010)
Undisturbed room /NA
10 healthy subjects COP displacement 10 subjects with NSLBP
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24. Mazaheri Biomechanics 22 healthy subjects COP displacement 22 subjects with et al. (2010) laboraNSLBP tory/NA
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COP displacement
AMTI, force platform
8 healthy subjects 8 subjects with NSLBP
26. Mitchell University/ et al. (2008) NA
3SPACE Fastrak 36 healthy subjects – Posture – Movement magni81 subjects with tude mild LBP 53 subjects with severe LBP
27. Mok et al. (2007)
NA/NA
10 healthy subjects Preparatory and resul- – Accension tant movements mag- – 7 sensors 10 subjects with nitude NSLBP
28. Mok et al. (2010)
NA/NA
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25. Mientjes et NA/NA Frank (1999)
11 healthy subjects – COP displacement – Accension 11 subjects with – Number of postural – Force platform NSLBP adjustements
NSLBP: increased COP displacement with and without visual feedback NSLBP may be a factor that modulates the posture-cognition interaction
– NSLBP: greater postural sways in the frontal plane in absence of visual feedback and in difficult tasks Global lumbar spine kinematics do not reflect regional lumbar spine kinematics, which has implications for interpretation of measures of spinal posture – NSLBP: used preparatory extension less frequently than healthy subjects – Reduced spinal movement is associated with compromised quality of trunk control – NSLBP: slower reaction times – NSLBP: took longer to regain postural stability – NSLBP: increased number of postural changes but no significant difference in COP displacement
29. Newcomer NA/NA et al. (2000a)
20 healthy subjects Repositioning accuracy 20 subjects with NSLBP
– 3Space Tracker system – 2 magnetic sensors
– NSLBP: higher repositioning error in flexion and smaller in extension
30. Newcomer NA/NA et al. (2000b)
20 healthy subjects Repositioning accuracy 20 subjects with NSLBP 13 healthy subjects COP displacement 13 subjects with NSLBP
3Space Tracker system
– NSLBP: no significant differences in the repositioning tasks
Equitest, Neurocom Int. Inc., platform
No significant differences between the 2 groups in the COP displacements with and without a visual feedback and in expectation of an external perturbation
31. Popa et al. (2007)
NA/NA
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Table 2, continued Studies
Setting and health worker 32. Salavati et al. University (2009) biomechanics laboratory/ NA
Study samples
Assessment method
22 healthy subjects COP displacement 22 subjects with NSLBP
Equipment
Results
Bertec 4060-10 force platform
NSLBP: no significant differences in postural control during cognitive dual-tasking
49 healthy subjects Movement perception Trunk rotation measurement – NSLBP: less ability to sense a change in lumbar position threshold unit 57 subjects with – Lumbar fatigue impairs the NSLBP ability to sense a change in lumbar position
34. Van Daele NA/NA et al. (2009)
20 healthy subjects COP displacement 19 subjects with NSLBP
– Vicon612-datastation – 7 videocameras
– NSLBP: higher postural sway than healthy subjects
35. Van Daele NA/NA et al. (2010)
21 healthy subjects COP displacement 21 subjects with NSLBP
– Vicon612-datastation – 7 videocameras
NSLBP: decrease in COP displacements during cognitive dualtask
36. Van Dieën NA/NA et al. (2010)
164 healthy subjects 79 subjects with recent NSLBP 58 subjects with chronic NSLBP
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– No differences in the COP displacement between healthy and low back pain sufferers subjects – Greater COP displacement in subjects with recent NSLBP
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33. Taimela et al. NA/ (1999) Physical therapist
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NA: Not Available; NSLBP: Non-specific low back pain; COP: Center of pressure.
Fig. 3. Graphic distribution of the V.A.S. values divided into studies that have found – or not found – a proprioceptive deficit. 220
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3.5. Implications for clinical practice After an initial inspection of the articles it became evident that the information derived from the studies could not provide a complete picture of the items that contribute to the definition of “applicability in rehabilitation practice”.
The data from the studies provided us with information on the equipment and methods used, on the error of measurement and on the validity of the instruments as well. However, only 7 studies (19%) provided information concerning the setting and only 5 (14%) identified the person performing the assessment and his/her professional competency. Little information was pro-
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4. Discussion
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The main outcome of this systematic review concerning the methods used to assess neuromotor capacity in NSLBP is that static tests, such as COP displacement tests, resulted to be more effective in identifying proprioceptive deficits (74% of selected studies) than dynamics tests, like trunk repositioning and reproduction of movements, which failed to find significant differences between NSLBP patients and controls in 50% of the selected high-quality studies. Nevertheless, it has to be underlined that the large number of studies published on this topic reveals remarkable conflicting results and fundamental limitations that should be carefully considered by clinicians and researchers in their future research strategies and study designs. Among the several reasons for the inconsistent findings between the investigated studies we found the rest time between two succeeding trials, the reliability of the equipment used, the number of pre-trials, V.A.S. values of the population and the fatiguing effect of the
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trials. Additionally, dynamic trials (repositioning tests) were carried out in the three spatial planes resulting from the evaluation of flexion-extension, lateral and rotational movements. This limited capacity to offer a wide range of movements could be another factor that may directly influence subjects’ performance. It has also been suggested that a greater number of trials on a stabilometric platform seems to improve outcomes and overall reliability [37]. Grimstone and Hodges [8] and Hamaoui et al. [9] have shown that breathing (specifically by varying volumes and frequency of ventilation) is a factor that intrinsically destabilizes posture in subjects with low back pain. Another particular aspect that demands further evidence pertains to the influence of NSLBP on posturecognition interaction as cognitive functions (attention, concentration) play a key role in postural control and distracting tasks may differently affect posture stabilization in unimpaired and NSLBP subjects. Indeed, Salavati et al. [13] and Van Daele et al. [27] found no differences in the neuromotor controls of the trunk between subjects with low back pain and healthy controls during dual-task performance, whereas Mazaheri et al. [12], who adopted more accurate parameters in the evaluation, attained opposite findings. With regards to fatigue, which represents a cause of reduced ability to perceive a change in position in the lumbar region in patients with chronic low back pain [7,38], remarkable attention has to be put on the study of Petersen et al. [38]. The author(s) searched for
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vided on the execution of the tests, namely the duration, and the time needed to process data. Considering that in clinical practice a standard physiotherapy session lasts 30 minutes, it appears that the tests proposed in the literature may hardly be replicated by the physiotherapist as this would require a greater amount of time than the available.
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Fig. 4. Graphic distribution of the number of trials divided into studies that have found – or not found – a proprioceptive deficit. 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291
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Mann et al. (2010) Mazaheri et al. (2010) Mientjes et Frank (1999) Mitchell et al. (2008)
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27. 28. 29. 30. 31. 32. 33.
Mok et al. (2007) Mok et al. (2010) Newcomer et al. (2000a) Newcomer et al. (2000b) Popa et al. (2007) Salavati et al. (2009) Taimela et al. (1999)
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Van Daele et al. (2009) Van Daele et al. (2010) Van Dieën et al. (2010)
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NA: Not available; ∗ With fatiguing procedure. 292 293 294 295 296 297 298 299 300 301 302 303 304 305
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Georgy (2011) Gill et Callaghan (1998) Grimstone et Hodges (2003) Hamaoui et al. (2004) Hamaoui et al. (2002) Harringe et al. (2008) Henry et al. (2006) Koumantakis et al. (2002) Lafond et al. (2009) Lam et al. (1999) Lee et al. (2010) Luoto et al. (1996) Luoto et al. (1998)
V.A.S. NA NA 1.5 ± 1.8 2.2 ± 1.5 1.2 ± 1.5 NA 2 ± 2.2 NA 4.3 ± 0.9 1.4 ± 0.8 6.3 ± 8.2 NA
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Journal of Back and Musculoskeletal Rehabilitation 00 (2014) 1–14 DOI 10.3233/BMR-140533 IOS Press
Review Article
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Methods for the assessment of neuromotor capacity in non-specific low back pain: Validity and applicability in everyday clinical practice
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Jorge Hugo Villafañea,∗, Luca Zanettib , Maria Isgròa , Joshua A. Clelandc,d , Lucia Bertozzie , Massimiliano Gobbof and Stefano Negrinia,f a
IRCCS Don Gnocchi Foundation, Milan, Italy School of Physiotherapy, University of Brescia, Italy c Department of Physical Therapy, Franklin Pierce University, Concord, NH, USA d Physical Therapist, Rehabilitation Services, Concord Hospital, NH, USA e School of Physical Therapy, Alma Mater Studiorum, University of Bologna, Bologna, Italy f Department of Clinical and Experimental Sciences, University of Brescia, Italy
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Abstract. BACKGROUND: Physiotherapists and clinicians require methods that can be used in everyday practice for measuring proprioception of the trunk in individuals with non-specific low back pain (NSLBP). OBJECTIVE: Our objective was to conduct a systematic literature review of methods used for assessment of proprioception of the trunk in individuals with non-specific low back pain METHOD: Data were obtained from MEDLINE, CINAHL, Embase, PEDro and CENTRAL databases from their inception to December 2011. Reference lists of the selected reviews were hand searched for other potentially relevant studies. Randomized and nonrandomized controlled studies proprioception of the trunk in individuals with low back pain were selected. Thirty-six studies satisfied the selection criteria and were included in this review. RESULTS: Two reviewers independently selected the studies, conducted the quality assessment, and extracted data from each study. The Strobe scale was used to evaluate the scientific rigor of each selected study. CONCLUSIONS: This systematic review covered all the relevant literature, but none of the included studies offered a valid, reliable and feasible method to assess the neuromotor capacity in everyday physiotherapy clinical practice. Keywords: Non-specific low back pain, low back pain, proprioception, motor control, equilibrium, balance, kinesthesia, repositioning error, clinical applicability
∗ Corresponding
author: Jorge Hugo Villafañe, Regione Generala 11/16, Piossasco (10045), Turin. Italy. Tel.: +39 3395857563; E-mail: [email protected].
1. Introduction
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Non-specific low back pain (NSLBP) is the most common musculoskeletal disorder affecting about 84% of the population, with a prevalence of 23% of individuals suffering from chronic non-specific low back pain
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c 2014 – IOS Press and the authors. All rights reserved ISSN 1053-8127/14/$27.50
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2.2. Study selection
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Several criteria were used to select eligible studies. Articles were included if the study design was a clinical trial and were written in English, German, or Italian. We included randomized and non-randomized controlled studies with no restriction of subjects age, which considered patients with NSLBP only. Articles were excluded if: (1) the study had an inappropriate design (i.e., not a clinical trial such as observational studies); (2) subjects had specific low back pain (i.e., structural deformities of the trunk like scoliosis, fractures, spondylolysis, spondylolisthesis, any surgery, symptomatic lumbar disc herniations, radicular symptoms, cauda equina syndrome, rheumatologic diseases, osteoporosis, infections, cancer); (3) subjects had vestibular diseases or conditions that cause a specific balance impairment; (4) patients were diagnosed for acute low back pain (considered here < 30 days); (5) patients underwent electromyographic evaluation of the stabilizing ability of the trunk (in that this type of kinesiological analysis was not considered as feasible in everyday clinical practice).
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2.3. Data extraction and quality assessment
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The literature search, data extraction, and quality assessment procedures were performed by two independent researchers (L. Z. and M.G.). Score discrepancies were rare and any discrepancies were resolved by consensus. The titles and abstracts of the selected articles generated by the search strategy were first screened to eliminate irrelevant articles. The full text of each of the remaining articles was then reviewed to determine eligibility. Eventually, the scientific rigor of the eligible studies was assessed with a modified Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [10] scale. Among the 22 items of the scale, we excluded the items referring to the title, introduction and discussion (7 elements) as we aimed at focussing exclusively on the quality of methods and results of the studies (Table 1). We used a modified version of STROBE scale since a valid, reliable and universally accepted scale for the assessment of the methodological quality of physical therapy trials still needs to be developed [11]. To note that STROBE
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gibility criteria. A forward search with the Science Citation Index was conducted to identify and examine all subsequent articles that referenced the selected articles.
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(CNSLBP) [1]. Although the natural history of this condition appears to be favorable, the rate of chronicity is thought to represent the most prevalent and costly health problem in world [2]. In an attempt to reduce the social impact of NSLBP individuals often present to physical therapy [3]. A comprehensive examination is necessary for subgrouping and to determine appropriate interventions for this patient population [1]. Despite subgrouping, physiotherapists typically do not treat all the deficits associated with NSLBP such as, for instance, proprioception [4,5]. Proprioception is defined as the complex interaction between afferent and efferent inputs to control body movement and posture [6]. If any of the afferent components are damaged, proprioceptive deficits may occur. Additionally, fatigue [7] and respiration [8, 9] have been recognized as factors that can potentially destabilize posture and performance in individuals with NSLBP and could have important implications in the rehabilitation process. To our knowledge no systematic reviews have been conducted in the attempt to identify the most valid and reliable methods for proprioception assessment in individuals with NSLBP that may also prove to be feasible for physiotherapists in everyday clinical practice. The objective of this systematic literature review was to examine the methods used for assessment of proprioception of the trunk in individuals with NSLBP and investigate their applicability in everyday practice to enhance physical therapy.
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The following databases were searched from 1980 to December 2011: MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, Physiotherapy Evidence Database (PEDro) and Cochrane Central Register of Controlled Trials (CENTRAL). See Quorom diagram (Fig. 1). English language-only key word searches were used with combinations of terms including “non-specific low back pain”, “low back pain”, “proprioception”, “motor control”, “equilibrium”, “balance”, “kinesthesia”, “repositioning error”. The combinations, for instance, included: low back pain AND proprioception, low back pain AND motor control, and so on. The reference list of each selected article was hand-searched to identify other potential articles that might have fulfilled the eli-
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Literature Search:: n°184 Papers rejected after abstracts screening: n°134 Full papers obtained and screened: n°50 Papers included after hand search: n°11
Papers rejected after full text reading: n°25
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2.4. Criteria to judge clinical applicability of methods used to measure proprioception
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2.5. Data synthesis and analysis
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Kappa statistics were used to assess agreement between the two raters on article selection and Strobe ratings. The Strobe statement delineates essential items to be reported in cohorts research studies. Subsequently we selected studies for this review with a score 10.
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We are not aware of an existing operational definition of “applicability in everyday clinical practice” of specific tests. Consequently, before starting the research we defined a-priori the following set of criteria in order to determine the feasibility of performing the tests in clinical practice: – Setting where the assessment was carried out (i.e., clinic, laboratory, treatment room) – Qualification of the operator performing the test (i.e., physical therapist, physician, researcher) – Time needed for the execution of the test. Time needed to analyze the data from the tests – Instruments/devices required to perform the test – Cost of the instruments/devices – Knowledge of repeatability of measurements All selected studies where examined to determine if these criteria were present.
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3. Results
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Figure 1 shows the process of study selection. Initial searching identified 184 citations. Following the first screening, 134 articles were excluded and 50 citations were retained for the second screening. Eleven studies were retrieved through hand-searching of the references in the previously selected papers. Using the inclusion and exclusion criteria a further 25 articles were excluded. In total, 36 articles were selected for the review. See Table 2. The level of interrater reliability on article screening through reading of the titles and abstracts was excellent according to Fleiss (kappa = 0.85, 95% CI: 0.81–1.0), as was the article selection through reading of the full text of each of the remaining articles.
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3.1. Study characteristics
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The majority of authors (32/36, 89%) described the basic anthropometric characteristics of participants (sex, age, height and weight). In addition, only 14 studies (39%) reported at least two parameters among training status, health status and job. With regard to the assessment methods, the most frequently performed tests were static tests as the displacement of the center of gravity (23/36, 64%) and dynamic tests such as the ability of repositioning or the reproduction of a movement (10/36, 28%). Other assessment methods were: the analysis of the amplitude of movement (3/36, 8%), the study of the motion perception threshold (2/36, 6%) and the examination of psychomotor speed (1/36, 3%).
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scale gives particular attention to confounders which critically affect the quality and relevance of outcome data. Each item was scored a maximum of 1 point if full reporting criteria were met and 0 point if the criteria were not met, for a total possible score of 15 points.
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Fig. 1. Flowchart of papers.
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J.H. Villafañe et al. / Methods for the assessment of neuromotor capacity in non-specific low back pain Table 1 STROBE statement: Checklist of items that should be included in reports of cohort studies Item No Recommendation 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract (b) Provide in the abstract an informative and balanced summary of what was done and what was found
Title and Abstract
2 3
Explain the scientific background and rationale for the investigation being reported State specific objectives, including any prespecified hypotheses
Methods Study design Setting
4 5
Participants
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Variables
7
Data sources/measurement
8∗
Bias Study size Quantitative variables
9 10 11
Statistical methods
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Present key elements of study design early in the paper Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection (a) Give the eligibility criteria, and the sources and methods of selection of participants. Describe methods of follow-up (b) For matched studies, give matching criteria and number of exposed and unexposed Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if applicable For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group Describe any efforts to address potential sources of bias Explain how the study size was arrived at Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why (a) Describe all statistical methods, including those used to control for confounding (b) Describe any methods used to examine subgroups and interactions (c) Explain how missing data were addressed (d) If applicable, explain how loss to follow-up was addressed (e) Describe any sensitivity analyses
2–3 3 4 4 5
5–6 6
5 5
Other analyses Discussion Key results Limitations
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Interpretation
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Generalisability
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Other information Funding
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∗ Give
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Outcome data Main results
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(a) Report numbers of individuals at each stage of study – eg numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completing follow-up, and analysed (b) Give reasons for non-participation at each stage (c) Consider use of a flow diagram (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential confounders (b) Indicate number of participants with missing data for each variable of interest (c) Summarise follow-up time (eg, average and total amount) Report numbers of outcome events or summary measures over time (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and why they were included (b) Report category boundaries when continuous variables were categorized (c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period Report other analyses done – eg analyses of subgroups and interactions, and sensitivity analyses
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Results Participants
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Introduction Background/rationale Objectives
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Summarise key results with reference to study objectives Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and magnitude of any potential bias Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from similar studies, and other relevant evidence Discuss the generalisability (external validity) of the study results
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Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based
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information separately for exposed and unexposed groups.
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Fig. 2. Graphic distribution of the studies depending on their methodological quality.
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Twenty one of the 36 studies (71%) were identified as having high methodological rigor. Figure 2 shows the graphic distribution of studies according to the scores obtained from the assessment of their methodological quality.
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3.3. Confounders
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The influence of sex, age, height, weight and pain between groups was quantified in 19/21 studies with high methodological rigor (90%), and comprehensively, in 22/36 studies (61%) overall. Other parameters considered as “confounders” were the number of trials carried out and the value of V.A.S. (Visual Analogue Scale) as a measure of pain at the time of the tests (Table 2). Unfortunately it was not possible to obtain all data from each study. A third of the articles did not present V.A.S. values as information of the extent of pain, while other three authors [8,12,13] have provided approximate values (< 2) compared to the precise scores provided by the majority of the studies; an average V.A.S. value of 1,5 has been assigned to them. Figures 3 and 4 show the distributions of the two parameters grouped in studies that have or have not found statistically significant differences in the neuromotor ability of the trunk between subjects with low back pain and healthy controls. In regards to those studies that reported two VAS values (one for men and one for women), the average value was calculated and reported here.
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3.4. Low back pain and proprioceptive deficits
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In general, the measurements reported by the studies have shown a wide variability.
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3.4.1. COP (center of pressure) displacement In comparison to healthy subjects, subjects with low back pain seem to exhibit greater postural sway: this difference was significant in most of the studies (17/36, 52%). In particular, 3 studies demonstrated that the deficit is greater in absence of visual feedback [14– 16], 5 studies have found greater COP displacements in unstable conditions or during difficult tests [15–19], while 2 studies showed the destabilizing effect of respiration on postural control [8,9]. Only one study [19], has distinguished between the center of mass and center of pressure showing different results between the two parameters. Additionally, patients with low back pain exhibited a higher COP displacement speed [15, 18,21–23]. No significant differences between cases and controls were found in 6 studies [13,23,25–28]. 3.4.2. Capacity of repositioning and of reproducing a movement The studies that investigated the neuromotor control of the spine in subjects with low back pain through the capacity to reproduce a movement have failed to result in agreement. Some studies [14,29–32], have demonstrated the existence of a reduced motor perception; conversely, other studies [4,33–36] have failed to show a statistically significant difference in the ability of repositioning between patients with NSLBP and controls.
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J.H. Villafañe et al. / Methods for the assessment of neuromotor capacity in non-specific low back pain Table 2 Studies description Studies
1. Alexander et Kinney LaPier (1998)
Setting and Study samples Assessment method health worker NA/NA 15 healthy subjects COP displacement 15 subjects with NSLBP
Equipment
Results
Balance Master, Neurocom NSLBP: increased COP displacement with and without visual feedback
31 healthy subjects Movement magnitude 3SPACE Fastrak 23 subjects with NSLBP
NSLBP: smaller movement magnitude
3. Brumagne NA/NA et al. (2008a)
33 healthy subjects – COP displacement – 2 piezo-resistive electro- – No differences between the two groups when visual feedback is goniometers – Ability to repro56 subjects with permitted duce a movement – Bertec Corporation, force NSLBP – NSLBP: greater anterior sway platform with and without a in absence of visual feedback visual feedback – NSLBP: greater anterior sway in anticipation of postural instability
4. Brumagne NA/NA et al. (2008b)
24 healthy subjects COP displacement 21 subjects with NSLBP
5. Brumagne NA/NA et al. (2000)
21 healthy subjects Repositioning accuracy 23 subjects with NSLBP
6. Brumagne NA/NA et al. (2004)
20 healthy subjects COP displacement 20 subjects with NSLBP
7. Claeys et al. NA/NA (2011)
50 healthy subjects COP displacement 106 subjects with LBP
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2. Barrett et al. NA/ (1999) Physical therapist?
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– Bertec Corporation, force – NSLBP: greater sway in instability conditions platform – NSLBP: rely more on ankle – 2 piezo-resistive proprioception to control their accelerometers posture even in conditions – 2 muscular vibrators when this strategy is not the (Maxon motors) most appropriate (unstable support surfaces) – Muscular vibrator (VB100, Dynatronic) – Piezo-resistive electrogoniometer
– NSLBP: greater repositioning error
– Bertec Corporation, force NSLBP: rely more on ankle stratplatform egy to control their posture – Muscular vibrator – Bertec Corporation, force – NSLBP: rely more on ankle platform proprioception to control their – 2 piezo-resistive posture and have a reduced caaccelerometers pacity to switch postural con(ICSensors) trol strategy
8. Della Volpe NA/NA et al. (2006)
12 healthy subjects COP displacement 12 subjects with NSLBP
Equitest, Neurocom Int. Inc, platform
– No significant differences between the 2 groups in the COP displacement in stable conditions – NSLBP: greater sagittal sway in unstable conditions
9. Descarreaux NA/NA et al. (2005)
15 healthy subjects Repositioning accuracy 7 subjects with mild NSLBP 9 subjects with severe NSLBP
Loredan Biomedical
– NSLBP: when given a learning period, they were able to reproduce trunk position with a spatial accuracy similar to healthy subjects, even if they changed some spatial and temporal parameters
10. Georgy (2011)
15 healthy subjects COP displacement 15 subjects with NSLBP 15 subjects with discogenic LBP
Biodex System 3 Pro Isokinetic Dynamometer
– SLBP: greater repositioning error
NA/NA
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Table 2, continued Studies
Setting and health worker NA/ Physical Therapist
Study samples
Assessment method
Equipment
Results – A significative difference exists in proprioception between subjects with low back pain and healthy subjects
12. Grimstone et NA/NA Hodges (2003)
10 healthy subjects Effect of respiration – Kistler, force platform – 6 sensors (Motionstar on postural control 10 subjects with movement analysis NSLBP system, ascension technology) – Respitrace 200, plethysmograph
NSLBP: respiration is a factor that destabilizes posture
13. Hamaoui NA/NA et al. (2004)
10 healthy subjects – COP displacement Bertec Corporation, force – Movement magni- platform 10 subjects with tude NSLBP
NSLBP: postural sway increase is not related to reduced spine range of motion
14. Hamaoui NA/NA et al. (2002)
10 healthy subjects Effect of respiration on postural control 10 subjects with NSLBP
– Bertec Corporation, force NSLBP: respiration is a factor that destabilizes posture platform – Respiration sensor
15. Harringe NA/NA et al. (2008)
18 healthy subjects COP displacement 11 subjects with NSLBP 17 lower extremities injury subjects 11 multiple injury subjects
AMTI, force platform
16. Henry et al. (2006)
24 healthy subjects COM and COP dis- – 3 infrared camera system, – NSLBP: reduced and delayed sagittal plane COP responses BTS placement 26 subjects with – NSLBP: the sagittal plane COP – AMTI, force platform NSLBP responses were larger in magnitude and delayed in onset.
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12 healthy subjects COP displacement 12 subjects with NSLBP
– OR6-2000 AMTI, force platform
– NSLBP: less postural changes in the sagittal plane, during prolonged standing – NSLBP: increased sways in static trials
3Space Fastrak
– NSLBP: repositioning accuracy similar to performances of healthy subjects of another study – NSLBP: overshot the neutral position more frequently than healthy individuals
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18 healthy subjects Abilty to reproduce a Lumbar Motion Monitor (LMM) 62 subjects with given position NSLBP
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17. Koumantakis NA/NA et al. (2002)
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NSLBP: increased COP displacement in unstable conditions and without visual feedback than lower extremities injury subjects
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20 healthy subjects Abilty to reproduce a Lumbar Motion Monitor given position (LMM) 20 subjects with NSLBP
11. Gill et Callaghan (1998)
19. Lam et al. (1999)
NA/NA
20 subjects with NSLBP
Repositioning accuracy
20. Lee et al. (2010)
University laboratory/NA
24 healthy subjects – Movement percep- Flock of Birds, Ascension tion threshold Technology Corp 24 subjects with – Repositioning NSLBP accuracy
– SLBP: greater movement perception threshold – No significant differences between healthy and low back pain sufferers in the repositioning tests – NSLBP: more errors in the passive repositioning tests than in the active
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J.H. Villafañe et al. / Methods for the assessment of neuromotor capacity in non-specific low back pain Table 2, continued Studies
21. Luoto et al. (1996)
Setting and health worker Undisturbed room/3 Physical therapists
Study samples
Assessment method
Equipment
Results
61 healthy subjects – Psycomotor speed Vertical force platform – COP displacement 68 subjects with mild NSLBP 31 subjects with severe NSLBP
– NSLBP: slower reaction times – NSLBP (women): worse postural control than healthy women
– NSLBP: greater postural instability – No significant differences between subjects with NSLBP and healthy controls in the sagittal displacement of COP in unstable conditions – NSLBP affects the one-footed postural control by increasing the speed of COP displacements
NA/3 Physical therapists
61 healthy subjects – COP displacement – Vertical force platform (also one-footed) – Muscular stimulators 68 subjects with mild NSLBP 31 subjects with severe NSLBP
23. Mann et al. (2010)
Undisturbed room /NA
10 healthy subjects COP displacement 10 subjects with NSLBP
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24. Mazaheri Biomechanics 22 healthy subjects COP displacement 22 subjects with et al. (2010) laboraNSLBP tory/NA
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COP displacement
AMTI, force platform
8 healthy subjects 8 subjects with NSLBP
26. Mitchell University/ et al. (2008) NA
3SPACE Fastrak 36 healthy subjects – Posture – Movement magni81 subjects with tude mild LBP 53 subjects with severe LBP
27. Mok et al. (2007)
NA/NA
10 healthy subjects Preparatory and resul- – Accension tant movements mag- – 7 sensors 10 subjects with nitude NSLBP
28. Mok et al. (2010)
NA/NA
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11 healthy subjects – COP displacement – Accension 11 subjects with – Number of postural – Force platform NSLBP adjustements
NSLBP: increased COP displacement with and without visual feedback NSLBP may be a factor that modulates the posture-cognition interaction
– NSLBP: greater postural sways in the frontal plane in absence of visual feedback and in difficult tasks Global lumbar spine kinematics do not reflect regional lumbar spine kinematics, which has implications for interpretation of measures of spinal posture – NSLBP: used preparatory extension less frequently than healthy subjects – Reduced spinal movement is associated with compromised quality of trunk control – NSLBP: slower reaction times – NSLBP: took longer to regain postural stability – NSLBP: increased number of postural changes but no significant difference in COP displacement
29. Newcomer NA/NA et al. (2000a)
20 healthy subjects Repositioning accuracy 20 subjects with NSLBP
– 3Space Tracker system – 2 magnetic sensors
– NSLBP: higher repositioning error in flexion and smaller in extension
30. Newcomer NA/NA et al. (2000b)
20 healthy subjects Repositioning accuracy 20 subjects with NSLBP 13 healthy subjects COP displacement 13 subjects with NSLBP
3Space Tracker system
– NSLBP: no significant differences in the repositioning tasks
Equitest, Neurocom Int. Inc., platform
No significant differences between the 2 groups in the COP displacements with and without a visual feedback and in expectation of an external perturbation
31. Popa et al. (2007)
NA/NA
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Table 2, continued Studies
Setting and health worker 32. Salavati et al. University (2009) biomechanics laboratory/ NA
Study samples
Assessment method
22 healthy subjects COP displacement 22 subjects with NSLBP
Equipment
Results
Bertec 4060-10 force platform
NSLBP: no significant differences in postural control during cognitive dual-tasking
49 healthy subjects Movement perception Trunk rotation measurement – NSLBP: less ability to sense a change in lumbar position threshold unit 57 subjects with – Lumbar fatigue impairs the NSLBP ability to sense a change in lumbar position
34. Van Daele NA/NA et al. (2009)
20 healthy subjects COP displacement 19 subjects with NSLBP
– Vicon612-datastation – 7 videocameras
– NSLBP: higher postural sway than healthy subjects
35. Van Daele NA/NA et al. (2010)
21 healthy subjects COP displacement 21 subjects with NSLBP
– Vicon612-datastation – 7 videocameras
NSLBP: decrease in COP displacements during cognitive dualtask
36. Van Dieën NA/NA et al. (2010)
164 healthy subjects 79 subjects with recent NSLBP 58 subjects with chronic NSLBP
si o
Unit with unstable sitting
– No differences in the COP displacement between healthy and low back pain sufferers subjects – Greater COP displacement in subjects with recent NSLBP
oo
fv
er
COP displacement
n
33. Taimela et al. NA/ (1999) Physical therapist
un
co
rre
ct
ed
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NA: Not Available; NSLBP: Non-specific low back pain; COP: Center of pressure.
Fig. 3. Graphic distribution of the V.A.S. values divided into studies that have found – or not found – a proprioceptive deficit. 220
221 222 223 224 225
3.5. Implications for clinical practice After an initial inspection of the articles it became evident that the information derived from the studies could not provide a complete picture of the items that contribute to the definition of “applicability in rehabilitation practice”.
The data from the studies provided us with information on the equipment and methods used, on the error of measurement and on the validity of the instruments as well. However, only 7 studies (19%) provided information concerning the setting and only 5 (14%) identified the person performing the assessment and his/her professional competency. Little information was pro-
226 227 228 229 230 231 232
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237 238 239
4. Discussion
241
The main outcome of this systematic review concerning the methods used to assess neuromotor capacity in NSLBP is that static tests, such as COP displacement tests, resulted to be more effective in identifying proprioceptive deficits (74% of selected studies) than dynamics tests, like trunk repositioning and reproduction of movements, which failed to find significant differences between NSLBP patients and controls in 50% of the selected high-quality studies. Nevertheless, it has to be underlined that the large number of studies published on this topic reveals remarkable conflicting results and fundamental limitations that should be carefully considered by clinicians and researchers in their future research strategies and study designs. Among the several reasons for the inconsistent findings between the investigated studies we found the rest time between two succeeding trials, the reliability of the equipment used, the number of pre-trials, V.A.S. values of the population and the fatiguing effect of the
244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260
co
un
242
rre
240
243
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trials. Additionally, dynamic trials (repositioning tests) were carried out in the three spatial planes resulting from the evaluation of flexion-extension, lateral and rotational movements. This limited capacity to offer a wide range of movements could be another factor that may directly influence subjects’ performance. It has also been suggested that a greater number of trials on a stabilometric platform seems to improve outcomes and overall reliability [37]. Grimstone and Hodges [8] and Hamaoui et al. [9] have shown that breathing (specifically by varying volumes and frequency of ventilation) is a factor that intrinsically destabilizes posture in subjects with low back pain. Another particular aspect that demands further evidence pertains to the influence of NSLBP on posturecognition interaction as cognitive functions (attention, concentration) play a key role in postural control and distracting tasks may differently affect posture stabilization in unimpaired and NSLBP subjects. Indeed, Salavati et al. [13] and Van Daele et al. [27] found no differences in the neuromotor controls of the trunk between subjects with low back pain and healthy controls during dual-task performance, whereas Mazaheri et al. [12], who adopted more accurate parameters in the evaluation, attained opposite findings. With regards to fatigue, which represents a cause of reduced ability to perceive a change in position in the lumbar region in patients with chronic low back pain [7,38], remarkable attention has to be put on the study of Petersen et al. [38]. The author(s) searched for
pr
236
ed
235
vided on the execution of the tests, namely the duration, and the time needed to process data. Considering that in clinical practice a standard physiotherapy session lasts 30 minutes, it appears that the tests proposed in the literature may hardly be replicated by the physiotherapist as this would require a greater amount of time than the available.
ct
233 234
fv
Fig. 4. Graphic distribution of the number of trials divided into studies that have found – or not found – a proprioceptive deficit. 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291
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23. 24. 25. 26.
Mann et al. (2010) Mazaheri et al. (2010) Mientjes et Frank (1999) Mitchell et al. (2008)
6 9 21 10
27. 28. 29. 30. 31. 32. 33.
Mok et al. (2007) Mok et al. (2010) Newcomer et al. (2000a) Newcomer et al. (2000b) Popa et al. (2007) Salavati et al. (2009) Taimela et al. (1999)
10 10 12∗ 19∗ 10 9 10∗
34. 35. 36.
Van Daele et al. (2009) Van Daele et al. (2010) Van Dieën et al. (2010)
pr
ed ct
rre co
un
3 12∗ 3
NA: Not available; ∗ With fatiguing procedure. 292 293 294 295 296 297 298 299 300 301 302 303 304 305
si o
3 20 3 20 15 4 72 15 32 3 26∗ –54∗ ND 12∗
er
Georgy (2011) Gill et Callaghan (1998) Grimstone et Hodges (2003) Hamaoui et al. (2004) Hamaoui et al. (2002) Harringe et al. (2008) Henry et al. (2006) Koumantakis et al. (2002) Lafond et al. (2009) Lam et al. (1999) Lee et al. (2010) Luoto et al. (1996) Luoto et al. (1998)
V.A.S. NA NA 1.5 ± 1.8 2.2 ± 1.5 1.2 ± 1.5 NA 2 ± 2.2 NA 4.3 ± 0.9 1.4 ± 0.8 6.3 ± 8.2 NA
