Comparison of Postural Balance between Subgroups of Nonspecific Low-back Pain Patients Based on O’Sullivan Classification System and Normal Subjects during Lifting

Document Type: RESEARCH PAPER

Authors

1 Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran

2 Department of Physical Therapy, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

Abstract

Background: Balance disorder is one of the most-studied fields in low-back pain patients (LBP). However, there is
insufficient information regarding the effect of LBP subgrouping on postural control. The purpose of the present study
was to compare postural control between subgroups of chronic nonspecific LBP and healthy subjects during lifting.
Methods: A total of 35 men with chronic LBP (19 active extension pattern [AEP] and 16 flexion pattern [FP]) and 15
healthy controls were enrolled in this cross-sectional study. Pooled LBP was subdivided based on the O’Sullivan’s
classification system (OCS). The participants were asked to lift a box from the ground to the waist level and hold it for
20 seconds. The load was 10% of the subject’s weight. Force plate system was used to record balance parameters,
including standard deviations (SDs) of center of pressure (COP) amplitude and COP velocity in anterior-posterior and
medial-lateral directions and mean total velocity. The test was divided into two static and dynamic phases. Data were
analyzed using one-way analysis of variance and independent t-test.
Results: There were no significant differences between pooled LBP and control groups in any of the variables, except
for the SD of the anterior-posterior direction velocity in the X-plane in the static phase (P=0.017). After classifying LBP,
the results showed that the healthy and AEP groups were significantly different in SD of COP velocity in the frontal plane
(P=0.021), mean total velocity (P=0.010), and SD of COP velocity in the sagittal plane (P=0.039).
Conclusion: The present study showed that postural control was not different between the pooled LBP and normal
groups. After classifying pooled LBP based on OCS, we found that the AEP showed different postural control as
compared to healthy controls in the dynamic phase. The FP and AEP exhibited different postural control relative to the
healthy controls in the static phase, and COP velocity was lower in those groups compared to the control group. The
results of this study support the concept of LBP classification.

Keywords

Main Subjects


1. Dankaerts W, O’Sullivan P, Burnett A, Straker L, Davey
P, Gupta R. Discriminating healthy controls and two
clinical subgroups of nonspecific chronic low back
pain patients using trunk muscle activation and
lumbosacral kinematics of postures and movements:
a statistical classification model. Spine. 2009;
34(15):1610-8.
2. Luomajoki H, Kool J, de Bruin ED, Airaksinen O.
Reliability of movement control tests in the lumbar
spine. BMC Musculoskelet Disord. 2007; 8(1):90.
3. van Dieën JH, Selen LP, Cholewicki J. Trunk muscle
activation in low-back pain patients, an analysis of the
literature. J Electromyogr Kinesiol. 2003; 13(4):333-51.
4. Henry SM, Hitt JR, Jones SL, Bunn JY. Decreased limits
of stability in response to postural perturbations
in subjects with low back pain. Clin Biomech. 2006;
21(9):881-92.
5. Maribo T, Schiøttz-Christensen B, Jensen LD, Andersen
NT, Stengaard-Pedersen K. Postural balance in low
back pain patients: criterion-related validity of centre
of pressure assessed on a portable force platform. Eur
Spine J. 2012; 21(3):425-31.
6. Qu X. Development and evaluation of postural control
models for lifting motions and balance control.
Virginia: Virginia Polytechnic Institute and State
University; 2008.
7. Commissaris DA, Toussaint HM. Load knowledge
affects low-back loading and control of balance in
lifting tasks. Ergonomics. 1997; 40(5):559-75.
8. Mazaheri M, Coenen P, Parnianpour M, Kiers H,
van Dieen JH. Low back pain and postural sway
during quiet standing with and without sensory
manipulation: a systematic review. Gait Posture.
2013; 37(1):12-22.
9. Hoffman SL, Johnson MB, Zou D, Van Dillen LR.
Differences in end-range lumbar flexion during
slumped sitting and forward bending between low
back pain subgroups and genders. Man Ther. 2012;
17(2):157-63.

10. Shahbazi Moheb Seraj M, Maroufi N, Ebrahimi
Takamjani I, Ahmadi A, Negahban H. The ratio of lumbar
to hip motion during the trunk flexion in patients
with mechanical chronic low back pain according to
o’sullivan classification system: a cross-sectional study.
Arch Bone Joint Surg. 2018; 6(6):560-9.
11. O’Sullivan P. Diagnosis and classification of chronic
low back pain disorders: maladaptive movement and
motor control impairments as underlying mechanism.
Man Ther. 2005; 10(4):242-55.
12. Dankaerts W, O’Sullivan PB, Straker LM, Burnett
AF, Skouen JS. The inter-examiner reliability of a
classification method for non-specific chronic low
back pain patients with motor control impairment.
Man Ther. 2006; 11(1):28-39.
13. Luomajoki H, Kool J, de Bruin ED, Airaksinen O.
Movement control tests of the low back; evaluation of
the difference between patients with low back pain
and healthy controls. BMC Musculoskelet Disord.
2008; 9(1):170.
14. O’sullivan PB. Lumbar segmental ‘instability’:
clinical presentation and specific stabilizing exercise
management. Man Ther. 2000; 5(1):2-12.
15. O’Sullivan P. Classification of lumbopelvic pain
disorders--why is it essential for management? Man
Ther. 2006; 11(3):169-70.
16. Sheeran L, Sparkes V, Caterson B, Busse-Morris M, van
Deursen R. Spinal position sense and trunk muscle
activity during sitting and standing in nonspecific
chronic low back pain: classification analysis. Spine.
2012; 37(8):E486-95.
17. Sadler E. Principal component analyses of joint
angle curves to examine lifting technique. [Doctoral
Dissertation]. Ontario, Canada: Queen‟s University;
2010.
18. Kollmitzer J, Oddsson L, Ebenbichler GR, Giphart JE,
DeLuca CJ. Postural control during lifting. J Biomech.
2002; 35(5):585-94.
19. Faber GS, Kingma I, Bakker AJ, van Dieën JH. Low-back 

loading in lifting two loads beside the body compared
to lifting one load in front of the body. J Biomech.
2009; 42(1):35-41.

20. Dickin DC, McClain MA, Hubble RP, Doan JB,
Sessford D. Changes in postural sway frequency
and complexity in altered sensory environments
following whole body vibrations. Hum Mov Sci.
2012; 31(5):1238-46.
21. Salavati M, Hadian MR, Mazaheri M, Negahban H,
Ebrahimi I, Talebian S, et al. Test-retest reliabty of
center of pressure measures of postural stability
during quiet standing in a group with musculoskeletal
disorders consisting of low back pain, anterior cruciate
ligament injury and functional ankle instability. Gait
Posture. 2009; 29(3):460-4.
22. Meng H, O’Connor DP, Lee BC, Layne CS, Gorniak SL.
Effects of adiposity on postural control and cognition.
Gait Posture. 2016; 43(1):31-7.
23. Kejonen P, Kauranen K. Reliability and validity of
standing balance measurements with a motion
analysis system. Physiotherapy. 2002; 88(1):25-32.
24. Salavati M, Mazaheri M, Negahban H, Ebrahimi I, Jafari
AH, Kazemnejad A, et al. Effect of dual-tasking on
postural control in subjects with nonspecific low back
pain. Spine. 2009; 34(13):1415-21.
25. Dankaerts W, O’Sullivan P, Burnett A, Straker L.
Differences in sitting postures are associated with
nonspecific chronic low back pain disorders when
patients are subclassified. Spine. 2006; 31(6):698-
704.
26. Astfalck RG, O’Sullivan PB, Straker LM, Smith AJ,
Burnett A, Caneiro JP, et al. Sitting postures and trunk
muscle activity in adolescents with and without
nonspecific chronic low back pain: an analysis based
on subclassification. Spine. 2010; 35(14):1387-95.
27. Shumway-Cook A, Williams MW. Motor control: theory
and practical applications. Philadelphia: Lippincqtt
Williams & Wilkins; 2001.
28. Nadler SF, Malanga GA, Bartoli LA, Feinberg JH,
Prybicien M, Deprince M. Hip muscle imbalance and low
back pain in athletes: influence of core strengthening.
Med Sci Sports Exerc. 2002; 34(1):9-16.
29. Mazaheri M, Heidari E, Mostamand J, Negahban H, van
Dieen JH. Competing effects of pain and fear of pain
on postural control in low back pain? Spine. 2014;
39(25):E1518-23.
30. Mann L, Kleinpaul JF, Pereira Moro AR, Mota CB,
Carpes FP. Effect of low back pain on postural stability
in younger women: Influence of visual deprivation. J
Bodyw Mov Ther. 2010; 14(4):361-6.
31. della Volpe R, Popa T, Ginanneschi F, Spidalieri R,
Mazzocchio R, Rossi A. Changes in coordination
of postural control during dynamic stance in
chronic low back pain patients. Gait Posture. 2006;
24(3):349-55.
32. Hodges PW, Moseley GL. Pain and motor control of the
lumbopelvic region: effect and possible mechanisms.
J Electromyogr Kinesiol. 2003; 13(4):361-70.
33. Van Hoof W, Volkaerts K, O’Sullivan K, Verschueren
S, Dankaerts W. Comparing lower lumbar kinematics
in cyclists with low back pain (flexion pattern)
versus asymptomatic controls--field study using a
wireless posture monitoring system. Man Ther. 2012;
17(4):312-7.
34. Astfalck RG, O’Sullivan PB, Smith AJ, Straker LM,
Burnett AF. Lumbar spine repositioning sense in
adolescents with and without non-specific chronic
low back pain--an analysis based on sub-classification
and spinal regions. Man Ther. 2013; 18(5):410-7.
35. van Dieën JH, Kingma I, Van der Bug J. Evidence for
a role of antagonistic cocontraction in controlling
trunk stiffness during lifting. J Biomech. 2003;
36(12):1829-36.
36. 36. Schelldorfer S, Ernst MJ, Rast FM, Bauer CM,
Meichtry A, Kool J. Low back pain and postural control,
effects of task difficulty on centre of pressure and
spinal kinematics. Gait Posture. 2015; 41(1):112-8.
37. van Dieën JH, Cholewicki J, Radebold A. Trunk muscle
recruitment patterns in patients with low back pain
enhance the stability of the lumbar spine. Spine.
2003; 28(8):834-41.
38. Hodges P, van den Hoorn W, Dawson A, Cholewicki J.
Changes in the mechanical properties of the trunk in
low back pain may be associated with recurrence. J
Biomech. 2009; 42(1):61-6.
39. Lafond D, Champagne A, Descarreaux M, Dubois JD,
Prado JM, Duarte M. Postural control during prolonged
standing in persons with chronic low back pain. Gait
Posture. 2009; 29(3):421-7.
40. Lee PJ, Rogers EL, Granata KP. Active trunk stiffness
increases with co-contraction. J Electromyogr
Kinesiol. 2006; 16(1):51-7.
41. Nielsen J, Sinkjær T, Toft E, Kagamihara Y. Segmental
reflexes and ankle joint stiffness during co-contraction
of antagonistic ankle muscles in man. Exp Brain Res.
1994; 102(2):350-8.
42. Salavati M, Mazaheri M, Negahban H, Ebrahimi I, Jafari
AH, Kazemnejad A, et al. Effect of dual-tasking on
postural control in subjects with nonspecific low back
pain. Spine. 2009; 34(13):1415-21.
43. Zeinalzadeh A, Talebian S, Naghdi S, Salavati M,
Nazary-Moghadam S, Zeynalzadeh Ghoochani B.
Effects of vision and cognitive load on static postural
control in subjects with and without patellofemoral
pain syndrome. Physiother Theory Pract. 2018;
34(4):276-85.
44. Nazary-Moghadam S, Salavati M, Esteki A, Akhbari
B, Keyhani S, Zeinalzadeh A. Gait speed is more
challenging than cognitive load on the stride-tostride
variability in individuals with anterior cruciate
ligament deficiency. Knee. 2018; 160(8):30921-9.
45. Brumagne S, Cordo P, Lysens R, Verschueren S,
Swinnen S. The role of paraspinal muscle spindles in
lumbosacral position sense in individuals with and
without low back pain. Spine. 2000; 25(8):989-94.
46. Gill KP, Callaghan MJ. The measurement of lumbar
proprioception in individuals with and without low
back pain. Spine. 1998; 23(3):371-7.
47. Craig CE, Goble DJ, Doumas M. Proprioceptive acuity
predicts muscle co-contraction of the tibialis anterior
and gastrocnemius medialis in older adults’ dynamic
postural control. Neuroscience. 2016; 322(1):251-61.

48. Van Daele U, Hagman F, Truijen S, Vorlat P, Van Gheluwe
B, Vaes P. Decrease in postural sway and trunk stiffness
during cognitive dual-task in nonspecific chronic low
back pain patients, performance compared to healthy
control subjects. Spine. 2010; 35(5):583-9.
49. Hodges PW. Pain and motor control: from the
laboratory to rehabilitation. J Electromyogr Kinesiol.
2011; 21(2):220-8.