Evaluating Sagittal Spinal Posture During Functional Tasks:

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1 Evaluating Sagittal Spinal Posture During Functional Tasks: Can Kinematics Differentiate Between Non-specific Chronic Low Back Pain Subgroups And Healthy Controls? Rebecca Hemming*, Liba Sheeran, Robert van Deursen, Valerie Sparkes School of Healthcare Sciences, Cardiff University, UK

2 Background Non-specific Chronic Low Back Pain (NSCLBP) accounts for approximately 85% of the back pain population NSCLBP is complex and highly heterogeneous therefore evidence-based subclassification approaches are needed A multi-dimensional classification approach has been developed (O Sullivan 2005) with an emerging evidence base (Dankaerts et al 2006; Fersum et al 2009; 2013) Bio-psycho-social approach Good inter-tester reliability Validity for subgroups identified in the physical domains Identifies a targeted management plan Classification-Based Cognitive Functional Therapy (CB-CFT)

3 Outline of the Multi-dimensional Classification Approach (O Sullivan et al, 2004; O Sullivan 2005) CLBP >12 weeks Red Flags e.g. Cancer, inflammatory disorders, infections, fractures Specific LBP e.g. disc prolapse, modic changes, stenosis, spondylolisthesis NSCLBP No clear pathoanatomical diagnosis Sub-group differences identified between AEP and FP groups: Motor Control Impairment Movement Impairment Regional lumbar spinal angles in sitting (Dankaerts et al, 2006; Astfalck et al, 2010) Direction-specific repositioning errors in sitting and standing (thoracic and lumbar) (Sheeran et al, 2012) Active Extension Pattern (AEP) Flexion Pattern (FP) Lateral Shift Pattern Passive Extension Pattern Multidirectional Pattern Adapted from Fersum et al (2013)

Clinical Features of Motor Control Impairment Sub-groups (O Sullivan et al, 2004; O Sullivan 2005) AEP FP Tendency to hold the lumbar spine actively into extension Pain provoked by extension-related

4 Clinical Features of Motor Control Impairment Sub-groups (O Sullivan et al, 2004; O Sullivan 2005) AEP FP Tendency to hold the lumbar spine actively into extension Pain provoked by extension-related postures / activities (standing, erect sitting, overhead activities, fast walking, running and swimming) Pain eased by flexion postures/ activities (e.g. crook lying, slouched sitting). Loss of segmental lordosis Functional loss of motor control into flexion Pain provoked by flexion-related postures / functional activities (e.g. slouched sitting, forward bending, cycling) Pain eased by extension postures/ activities (e.g. standing, walking)

5 Aim To determine whether differences in total and regional sagittal spinal postures exist between FP, AEP and healthy groups during static postures and functional tasks Total C7 Regional C7 Upper Thoracic C7 T6 Static postures Functional Tasks Total Thoracic C7 T12 T6 T6 Lower Thoracic T6 T12 Box lift and replace Sit-to-stand T12 T12 Upper Lumbar T12 L3 Total Lumbar T12 S2 L3 S2 L3 Lower Lumbar L3 S2 S2 Usual Sitting Usual Standing Reach Up Step up and down Bend to pick up pen

(VICON) custom designed spinal marker set Outputs Mean regional sagittal

6 Methods Study Design Observational, cross-sectional study 50 NSCLBP subjects (27 FP, 23 AEP) 28 healthy control subjects 3D motion analysis (VICON) custom designed spinal marker set Outputs Mean regional sagittal spinal angles (relative to the pelvis) Analysis One-way ANOVAs (p<0.05) Post-hoc Bonferroni

7 Variable Gender Males Females Baseline Subject Characteristics AEP N=23 4 (17.4%) 19 (82.6%) FP N=27 21 (77.8%) 6 (22.2%) Control N=28 12 (42.9%) 16 (57.1%) Significance (p<0.05) p=0.000* Age (years) 43.7 (11.2) 41.0 (10.0) 38.5 (11.2) p=0.238 Weight (kg) 68.9 (18.0) 82.5 (14.6) 72.9 (15.2) p=0.005* Height (cm) (10.2) (8.7) (7.3) p=0.000* BMI 25.2 (5.6) 26.5 (3.4) 25.4 (4.8) p=0.145 International Physical Activity Questionnaire (Short Form) (MET-min/week) p=0.666 Oswestry Disability Index 22.5 (11.6) 21.6 (10.0) - p=0.773 Distress and Risk Assessment Method STarT Back Tool 3.4 (2.2) 3.3 (2.1) - p=0.834 Normal 6 (26.1%) 11 (42.3%) - At Risk 11 (47.8%) 12 (46.2%) - Depressed 6 (26.1%) 3 (11.5%) - p=0.465 Visual Analogue Scale 4.6 (1.4) 4.5 (1.4) - p=0.986 Tampa Scale of Kinesiophobia 37.5 (6.8) 37.6 (5.3) - p=0.993

8 Angle (degrees) Results: Usual Sitting (Total) Flexion Total Thoracic Total Lumbar C * T T12 36 AEP FP Control -25 AEP FP Control L3 Extension * = significant at p<0.05 S2 Significant difference only observed between the FP and AEP group in the total lumbar spine (FP more flexed compared to AEP) (NB: Bars represent range; dots represent mean)

9 Angle (degrees) Angle (degrees) Results: Usual Sitting (Regional) Flexion 32 Upper Thoracic 15 Upper Lumbar C * * T6 30 AEP Lower Thoracic FP Control -5 AEP FP Control Lower Lumbar Extension * * L3 T12 S2 5 AEP FP Control AEP FP Control Significant differences between FP and both AEP and control groups observed in the upper lumbar and lower thoracic spine regions

10 Summary of significant kinematic between group results (p<0.05) for all activities in each spinal region Total Thoracic Total Lumbar Upper Thoracic Lower Thoracic Upper Lumbar Lower Lumbar Static Posture Usual Sitting * * * ** Usual Standing ** Functional Task Sit-to-Stand * ** * Pick Up Pen (Bend Down) ** ** Reach Up * Step Down * * ** Step Up * ** Box Replace * ** Box Lift * * Stand-to-Sit * ** * Pick Up Pen (Replace) ** * Key: * = Significant increased flexion (p<0.05) in the FP vs.aep; * * = Significant increased flexion (p<0.05) in the FP vs. both AEP and control C7 T6 T12 L3 S2 Between group differences in the thoraco-lumbar spine are consistently present during static postures and functional tasks

11 Conclusions Differences in regional sagittal spinal postures exist between FP, AEP and healthy groups during static postures and functional tasks. Evaluation of regional (rather than total) spinal angles is crucial to identify sub-group differences. FP consistently adopt significantly more flexed postures in the thoraco-lumbar region compared to AEP and healthy individuals Supports previous findings in upper lumbar region in static postures (Dankaerts et al, 2006; Astfalck et al, 2010) but negates previous findings of differences in the lower lumbar spine (Dankaerts et al 2006) Novel findings can inform the development of specific CB-CFT interventions for NSCLBP subgroups Targeted thoraco-lumbar spinal movement re-education strategies are needed for NSCLBP sub-groups

12 Disclosure Declaration All authors have nothing to declare Acknowledgements

ASSESSMENT OF LUMBAR SPINE POSTURE DURING SITTING ON A DYNAMIC SITTING DEVICE (FLEXCHAIR )

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