Beruflich Dokumente
Kultur Dokumente
a r t i c l e
i n f o
Article history:
Received 10 March 2016
Received in revised form 16 September
2016
Accepted 20 September 2016
Keywords:
Low back pain
Prolonged standing
Muscle cocontraction
Fatigue
Spine posture
Movement
a b s t r a c t
Persons who develop low back pain from prolonged standing exhibit increased muscle cocontraction,
decreased movement and increased spine extension. However, it is unclear how these factors relate to
pain development. The purpose of this study was to use hip abductor fatigue to manipulate muscle activity patterns and determine its effects on standing behaviours and pain development. Forty participants
stood for two hours twice, once following a hip abductor fatigue exercise (fatigue), and once without
exercise beforehand (control). Trunk and gluteal muscle activity were measured to determine cocontraction. Lumbo-pelvic angles and force plates were used to assess posture and movement strategies. Visual
analog scales differentiated pain (PDs) and non-pain developers (NPDs). PDs reported less low back pain
during the fatigue session, with females having earlier reductions of similar scale than males. The fatigue
session reduced gluteal and trunk cocontraction and increased centre of pressure movement; male and
female PDs had opposing spine posture compensations. Muscle fatigue prior to standing reduced cocontraction, increased movement during standing and reduced the low back pain developed by PDs; the timing of pain reductions depended on spine postures adopted during standing.
2016 Elsevier Ltd. All rights reserved.
1. Introduction
The study of low back pain is a multi-faceted discipline, a reflection of the breadth and scope of the low back pain problem
(Balagu et al., 2012). Despite tremendous heterogeneity, there
has been success in uncovering pain pathways using homogenous
sub-groups (Fritz et al., 2007; Fairbank et al., 2011). One subgrouping method uses prolonged standing to dichotomize persons
based on whether or not asymptomatic persons develop acute
transient pain (Gregory and Callaghan, 2008; Nelson-Wong et al.,
2008).
Around half of asymptomatic adults develop low back pain during a 2-h standing exposure (Gregory and Callaghan, 2008; NelsonWong and Callaghan, 2010a; Sorensen et al., 2015). These persons,
termed pain developers (PDs), are up to three times more likely to
develop chronic low back pain requiring medical intervention in
the future than non-pain developers (NPDs) (Nelson-Wong and
Callaghan, 2014). Prolonged standing exposures are also common
in many work places (Tissot et al., 2009; Waters and Dick, 2015).
Corresponding author.
E-mail address: jack.callaghan@uwaterloo.ca (J.P. Callaghan).
http://dx.doi.org/10.1016/j.jelekin.2016.09.005
1050-6411/ 2016 Elsevier Ltd. All rights reserved.
Understanding the pain development pathway in prolonged standing could help reduce work-related low back pain and its associated occupational burdens (Gore et al., 2012; Murray and Lopez,
2013).
There have been three standing behaviours that differentiate
PDs from NPDs. First, PDs have increased gluteal and trunk muscular cocontraction (Nelson-Wong et al., 2008; Nelson-Wong and
Callaghan, 2010b; Marshall et al., 2011). Second, PDs move less frequently near the start of a prolonged standing exposure (Gallagher
et al., 2011; Gallagher and Callaghan, 2015). Lastly, PDs stand in
postures of greater spine extension (Gallagher et al., 2014;
Sorensen et al., 2015). These behaviours may interact to cause
the pain developed by PDs. Cocontraction about the hip and trunk
can hinder transient motion during standing (Nelson-Wong et al.,
2008; Nelson-Wong and Callaghan, 2010b), which may increase
cumulative loading, a factor previously related to low back pain
development (Norman et al., 1998; Marras et al., 2014).
Attempts have been made to address each of these behaviours
in isolation to varying degrees of success. A trunk stabilization
training program reduced low back pain in PDs, but only corrected
gluteus medius cocontraction in males (Nelson-Wong and
Callaghan, 2010a). Incorporating a 15-min sitting break after
45 min of standing temporarily reduced low back pain, but did
64
not prevent its accelerated development upon returning to standing (Gallagher et al., 2014). Standing on sloped surfaces was effective at reducing low back pain in PDs, but the resulting postures
were inconsistent between individuals (Nelson-Wong and
Callaghan, 2010c).
Muscle fatigue can be used to perturb natural standing behaviours in order to better understand how PDs develop low back
pain (Salavati et al., 2007; Enoka and Duchateau, 2008; Fox et al.,
2008). Since fatigue is exercise-dependent (Enoka and Duchateau,
2008), an exercise targeting muscles relevant to prolonged standing would be a logical starting point. The hip abductors (gluteus
medius, gluteus minimus and tensor fascia latae) are associated
with the low back pain developed during standing (Nelson-Wong
et al., 2008; Nelson-Wong and Callaghan, 2010b) and the postural
control of standing (Winter et al., 1996; Salavati et al., 2007), and
are therefore a target for muscle fatigue likely to influence the
way PDs or NPDs may stand.
The purpose of this study was to determine the role of muscular
activity in the development of low back pain during prolonged
standing using a hip abductor fatigue protocol to perturb standing
patterns in PDs and NPDs. It was hypothesized that the hip abductor fatigue protocol would reduce hip and trunk muscle cocontraction during standing, and consequently reduce pain developed
while standing.
2. Methods
2.1. Participants
Twenty males (23.7 2.7 years; 1.82 0.06 m; 85.0 12.8 kg)
and 20 females (22.7 3.0 years; 1.65 0.06 m; 62.0 9.2 kg) were
recruited from a university population. Participants were excluded
if: (1) they reported low back or hip surgery, (2) experienced low
back pain that required rest from daily activities, (3) they were
employed in an occupation requiring prolonged standing, or (4)
could not stand continuously for 2 h. This study was approved by
an ethics review committee at the university and all participants
gave their written informed consent prior to participating.
2.2. Instrumentation and protocol
Participants completed two, 2-h standing sessions at the same
time of day separated by at least seven days. Instrumentation consisted of surface electromyography of three muscles bilaterally
(EMG), motion capture of the lumbar spine and pelvis segments,
centre of pressure measures of each foot using force plates, and
self-reported low back pain using a 100 mm visual analog scale
(VAS).
Muscle activity was measured bilaterally of the lumbar-level
erector spinae (LES 5 cm lateral to the L3 spinous process, oriented superiorly), gluteus medius (GMD halfway between the
iliac crest and posterior aspect of the greater trochanter, oriented
superiorly), and external oblique (EXO along a line joining the
ipsilateral costal margin to the contralateral pubic tubercle, oriented supero-laterally). Electrode placements were confirmed
through palpation and muscle testing. A reference electrode was
placed on the rib cage. For each muscle, the skin was shaved using
disposable razors and cleaned using an abrasive cloth soaked in a
60% ethanol solution prior to electrode application. Two Ag/Ag-Cl
disc electrodes (Blue Sensor, Medicotest Inc., lstykke, Denmark)
were applied over each muscle with a 2 cm inter-electrode distance; signals were differentially amplified (AMT-8, Bortec, Calgary, AB, Canada; CMRR: 115 dB; Impedance: 1010 X; Gain range
utilized: 5002000) and band pass filtered from 10 to 1000 Hz
prior to sampling at 2048 Hz (1st Principles, Northern Digital,
65
CCI
N
X
EMGlowi
i1
EMGhighi
EMGhighi EMGlowi
3. Results
1
3.1. VAS scores
Motion capture data were used to compute two threedimensional time-varying angles using Visual 3D software (v5,
C-Motion Inc., Germantown, MD, USA): pelvic tilt (S1 cluster relative to global coordinate system) and lumbar curvature (L1 cluster
relative to S1 cluster). The sagittal plane components of each angle,
assumed to be the first rotation, were extracted and averaged in
each 15-min block.
Force plate data were used to compute indicators of transient
movements. For the anterior-posterior direction, centre of pressure
data, computed separately for both feet, were combined into a single centre of pressure measure (Winter, 2009). The anteriorposterior component was identified and used to compute shifts
and fidgets (Duarte and Zatsiorsky, 1999; Gallagher et al., 2011).
The shift and fidget frequencies within each 15-min block were
recorded, and the anterior posterior movement index (APMI) was
computed using Eq. (2). For the medial-lateral direction, the relative weighting of the vertical ground reaction force was computed,
and used to determine medial-lateral body weight transfers (BWT)
(Gallagher and Callaghan, 2015). Two threshold magnitudes were
selected, representing a transfer of 10% (small) and 30% body
weight (large). The frequency of each size of BWT was summed
within a 15-min block.
APMI
q
2
2
shifts fidgets
66
Table 1
Physical characteristics of PDs and NPDs.
Measure
PDs
NPDs
Probability
Age (years)
Height (m)
Mass (kg)
Baseline VAS (mm)
23.4 3.0
1.75 0.10
74.1 13.4
0.4 1.5
1.0 3.5
23.0 2.8
1.73 0.11
73.2 15.8
0.6 2.9
0.3 1.0
0.7108
0.2093
0.4866
0.3764
0.2526
Control
Fatigue
Fig. 2. Low back pain development in PDs and NPDs during the control and fatigue sessions. Asterisks denote differences between sessions within PDs (p < 0.05). Female PDs
reported more pain than male PDs, and earlier onsets of pain reduction than males with fatigue. Error bars show standard deviations.
4. Discussion
PDs reported less low back pain while standing following a hip
abductor fatiguing exercise. Reduced trunk and hip muscle cocontraction and increased APMIs in the first hour of standing were
common to both male and female PDs. Changes in standing behaviour occurring prior to the onset of low back pain development
agrees with previous research aimed at differentiating PDs from
67
Fig. 5. Sagittal pelvic tilt angles split by gender. Male PDs (top) and female PDs
(bottom) had opposite responses with fatigue. Circles on the top panel denote
differences between the PD Control and PD Fatigue lines (p < 0.05). Asterisks on the
bottom panel denote differences between the PD Fatigue and NPD Fatigue lines
(p < 0.05). Error bars show standard errors.
Fig. 4. Changes in trunk cocontraction indices from the control to fatigue sessions.
Asterisks denote time blocks where the two sessions differ significantly (p < 0.05),
daggers denote trends (0.05 < p < 0.10). Error bars show standard errors.
Reductions in muscular rigidity, seen through smaller cocontraction indices, would be beneficial during prolonged standing
as it would facilitate increased movement and reduce the amount
of continuous static loading. Standing in itself does not appear to
be harmful, but can become a risk factor for pain development or
injury in the absence of muscular or postural variability
(Callaghan and McGill, 2001; Wells et al., 2007). Longer continuous
standing exposures should increase the cumulative loading of the
low back as there would be less movement to shift the load to
other tissues of the body, leading to a greater risk of local pain or
injury (Norman et al., 1998; Marras et al., 2014). Movement prior
to the development of pain interrupts static loading scenarios,
and can be effective at reducing low back pain development; seen
in the current study and previous work on sit-to-stand workstations (Davis and Kotowski, 2014; Karakolis and Callaghan, 2014).
While trunk cocontraction is often desired in dynamic tasks to mitigate shear loading and displacement of the lumbar spine
(Cholewicki and McGill, 1996; Granata and Marras, 2000), it
68
Fig. 6. Lumbar flexion angles split by gender. Male PDs (top) and female PDs
(bottom) had opposite responses with fatigue. Circles on the top panel denote
differences between the PD Control and PD Fatigue lines (p < 0.05). Asterisks on the
bottom panel denote differences between the PD Fatigue and NPD Fatigue lines
(p < 0.05). Error bars show standard errors.
69
Fig. 7. Changes in small (top) and large (bottom) Body weight transfers between genders and sessions. Shaded area shows the standard error about the mean (line without
markers). Females in the control session did not follow the steadily increasing pattern of the three other Gender-Session pairs.
4.4. Limitations
The sample size was fairly small and the variability in reported
low back pain was quite high. Corrections for multiple comparisons were advised against due to the small sample size to retain
statistical power. A larger sample should be tested using more con-
70
www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2375565&tool=
pmcentrez&rendertype=abstract>.
Fairbank, J., Gwilym, S.E., France, J.C., Daffner, S.D., Dettori, J., Hermsmeyer, J., et al.,
2011. The role of classification of chronic low back pain. Spine 36 (21 Suppl),
S19S42 (Phila Pa1976) Oct 1 [cited 2014 May 26]. <http://www.ncbi.nlm.
nih.gov/pubmed/21952188>.
Fox, Z.G., Mihalik, J.P., Blackburn, J.T., Battaglini, C.L., Guskiewicz, K.M., 2008. Return
of postural control to baseline after anaerobic and aerobic exercise protocols. J.
Athl. Train 43 (5), 456463. <http://www.pubmedcentral.nih.gov/articlerender.
fcgi?artid=2547864&tool=pmcentrez&rendertype=abstract>.
Fritz, J.M., Cleland, J.A., Childs, J.D., 2007. Subgrouping patients with low back pain:
evolution of a classification approach to physical therapy. J. Orthop. Sports Phys.
Ther. 37 (6), 290302. Jun [cited 2014 May 26]. <http://www.ncbi.nlm.nih.gov/
pubmed/17612355>.
Gallagher, E.J., Liebman, M., Bijur, P.E., 2001. Prospective validation of clinically
important changes in pain severity measured on a visual analog scale. Ann.
Emerg. Med. 38 (6), 633638.
Gallagher, K.M., Callaghan, J.P., 2015. Early static standing is associated with
prolonged standing induced low back pain. Hum. Mov. Sci. 44, 111121.
<http://linkinghub.elsevier.com/retrieve/pii/S0167945715300282>.
Gallagher, K.M., Campbell, T., Callaghan, J.P., 2014. The influence of a seated break
on prolonged standing induced low back pain development. Ergonomics 57 (4),
555562. Apr [cited 2014 May 3]. <http://www.ncbi.nlm.nih.gov/pubmed/
24734970>.
Gallagher, K.M., Nelson-Wong, E., Callaghan, J.P., 2011. Do individuals who develop
transient low back pain exhibit different postural changes than non-pain
developers during prolonged standing? Gait Posture 34 (4), 490495. Oct [cited
2014 Apr 30]. <http://www.ncbi.nlm.nih.gov/pubmed/21802955>.
Goffaux, P., Redmond, W.J., Rainville, P., Marchand, S., 2007. Descending analgesia
when the spine echoes what the brain expects. Pain 130 (12), 137143.
Gore, M., Sadosky, A., Stacey, B.R., Tai, K.-S., Leslie, D., 2012. The burden of chronic
low back pain: clinical comorbidities, treatment patterns, and health care costs
in usual care settings. Spine 37 (11), E668E677 (Phila Pa 1976) May 15 [cited
2014 May 8]. <http://www.ncbi.nlm.nih.gov/pubmed/22146287>.
Granata, K.P., Marras, W.S., 2000. Cost-benefit of muscle cocontraction in protecting
against spinal instability. Spine 25 (11), 13981404 (Phila Pa 1976).
Gregory, D.E., Callaghan, J.P., 2008. Prolonged standing as a precursor for the
development of low back discomfort: an investigation of possible mechanisms.
Gait Posture 28 (1), 8692. Jul [cited 2014 May 7]. <http://www.ncbi.nlm.
nih.gov/pubmed/18053722>.
Hgg, O., Fritzell, P., Nordwall, A., 2003. The clinical importance of changes in
outcome scores after treatment for chronic low back pain. Eur. Spine J. 12 (1),
1220. Mar [cited 2014 Apr 30]. <http://www.ncbi.nlm.nih.gov/pubmed/
12592542>.
Hoffman, M.D., Shepanski, M.A., Ruble, S.B., Valic, Z., Buckwalter, J.B., Clifford, P.S.,
2004. Intensity and duration threshold for aerobic exercise-induced analgesia
to pressure pain. Arch. Phys. Med. Rehabil. 85 (7), 11831187.
Karakolis, T., Callaghan, J.P., 2014. The impact of sit-stand office workstations on
worker discomfort and productivity: a review. Appl. Ergon. 45 (3), 799806.
Kelly, A.M., 1998. Does the clinically significant difference in visual analog scale
pain scores vary with gender, age, or cause of pain? Acad. Emerg. Med. 5, 1086
1090.
Kelly, A.M., 2001. The minimum clinically significant difference in visual analogue
scale pain score does not differ with severity of pain. Emerg. Med. J. 18 (3), 205
207. <http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1725574&
tool=pmcentrez&rendertype=abstract>.
Koltyn, K.F., 2000. Analgesia following exercise: a review. Sport Med. 29 (2), 8598.
Levine, D., Whittle, M.W., 1996. The effects of pelvic movement on lumbar lordosis
in the standing position. J. Orthop. Sports Phys. Ther. 24 (3), 130135.
Madigan, M.L., Davidson, B.S., Nussbaum, M.A., 2006. Postural sway and joint
kinematics during quiet standing are affected by lumbar extensor fatigue. Hum.
Mov. Sci. 25 (6), 788799.
Marras, W.S., Ferguson, S.A., Lavender, S.A., Splittstoesser, R.E., Yang, G., 2014.
Cumulative spine loading and clinically meaningful declines in low-back
function. Hum. Factors J. Hum. Factors Ergon. Soc. 56 (1), 2943. <http://hfs.
sagepub.com/cgi/doi/10.1177/0018720813496814>.
Marshall, P.W.M., Patel, H., Callaghan, J.P., 2011. Gluteus medius strength,
endurance, and co-activation in the development of low back pain during
prolonged standing. Hum. Mov. Sci. 30 (1), 6373. Mar [cited 2014 Apr 30].
<http://www.ncbi.nlm.nih.gov/pubmed/21227522>.
Mazaheri, M., Coenen, P., Parnianpour, M., Kiers, H., van Dien, J.H., 2013. Low back
pain and postural sway during quiet standing with and without sensory
manipulation: a systematic review. Gait Posture 37 (1), 1222. Jan [cited 2014
May 7]. <http://www.ncbi.nlm.nih.gov/pubmed/22796243>.
Mello, R.G.T., Oliveira, L.F., Nadal, J., 2007. Digital Butterworth filter for subtracting
noise from low magnitude surface electromyogram. Comput. Methods
Programs Biomed. 87 (1), 2835. Jul [cited 2014 May 9]. <http://www.ncbi.
nlm.nih.gov/pubmed/17548125>.
Mientjes, M.I., Frank, J.S., 1999. Balance in chronic low back pain patients compared
to healthy people under various conditions in upright standing. Clin. Biomech.
14 (10), 710716.
Murray, C.J.L., Lopez, A.D., 2013. Measuring the global burden of disease. N. Engl. J.
Med.
369
(5),
448457.
<http://www.nejm.org/doi/full/10.1056/
NEJMra1201534/nhttp://www.nejm.org/doi/pdf/10.1056/NEJMra1201534>.
Nelson-Wong, E., Callaghan, J.P., 2010a. Changes in muscle activation patterns and
subjective low back pain ratings during prolonged standing in response to an
71
Winter, D.A., 2009. Biomechanics and Motor Control of Human Movement. John
Wiley & Sons, Inc., Hoboken, NJ, USA (cited 2015 Jun 1). <http://www.
scopus.com/inward/record.url?eid=2-s2.0-84890253320&partnerID=
tZOtx3y1>.
Winter, D.A., Prince, F., Frank, J.S., Powell, C., Zabjek, K.F., 1996. Unified theory
regarding A/P and M/L balance in quiet stance. J. Neurophysiol. 75 (6), 2334
2343. <http://www.ncbi.nlm.nih.gov/pubmed/8793746>.