Dynamic multi-segmental postural control in patients with chronic non-specific low back pain compared to pain-free controls: A cross-sectional study

Michael A McCaskey, Brigitte Wirth, Corina Schuster-Amft, Eling D de Bruin, Michael A McCaskey, Brigitte Wirth, Corina Schuster-Amft, Eling D de Bruin

Abstract

Reduced postural control is thought to contribute to the development and persistence of chronic non-specific low back pain (CNLBP). It is therefore frequently assessed in affected patients and commonly reported as the average amount of postural sway while standing upright under a variety of sensory conditions. These averaged linear outcomes, such as mean centre of pressure (CP) displacement or mean CP surface areas, may not reflect the true postural status. Adding nonlinear outcomes and multi-segmental kinematic analysis has been reported to better reflect the complexity of postural control and may detect subtler postural differences. In this cross-sectional study, a combination of linear and nonlinear postural parameters were assessed in patients with CNLBP (n = 24, 24-75 years, 9 females) and compared to symptom-free controls (CG, n = 34, 22-67 years, 11 females). Primary outcome was postural control measured by variance of joint configurations (uncontrolled manifold index, UI), confidence ellipse surface areas (CEA) and approximate entropy (ApEn) of CP dispersion during the response phase of a perturbed postural control task on a swaying platform. Secondary outcomes were segment excursions and clinical outcome correlates for pain and function. Non-parametric tests for group comparison with P-adjustment for multiple comparisons were conducted. Principal component analysis was applied to identify patterns of segmental contribution in both groups. CNLBP and CG performed similarly with respect to the primary outcomes. Comparison of joint kinematics revealed significant differences of hip (P < .001) and neck (P < .025) angular excursion, representing medium to large group effects (r's = .36 - .51). Significant (P's < .05), but moderate correlations of ApEn (r = -.42) and UI (r = -.46) with the health-related outcomes were observed. These findings lend further support to the notion that averaged linear outcomes do not suffice to describe subtle postural differences in CNLBP patients with low to moderate pain status.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. Illustration of the measurement setup.
Fig 1. Illustration of the measurement setup.
Fig 2. Schematic representation of the defined…
Fig 2. Schematic representation of the defined segment angles.
ΘN = Neck angle; ΘL = Lumbar angle; ΘH = Hip angle; ΘK = Knee angle; ΘA = Ankle angle; ΘF = Foot angle; Marker positions (from head to toe): corner of the eye (orbital process of the zygomatic bone), acromion, anterior superior iliac spine, greater trochanter, lateral condyle of femur, lateral malleolus, 1st metatarsal bone.
Fig 3. Example data for kinematic analysis.
Fig 3. Example data for kinematic analysis.
Data of a medium performer (mean UI = .55) from the symptom-free CG (left) and low performer (mean UI = −.47) from the CNLBP group (right). The solid vertical lines indicate time point of platform release. The shaded areas indicate the active response phase (area of interest). The top panel shows CM trajectory and actual platform sway trajectory. The middle panel shows the normalized variance within and perpendicular to pre-perturbation joint configuration space. Lower panel shows the relative ratio of variance.
Fig 4. Group comparison of postural outcome…
Fig 4. Group comparison of postural outcome measures.
Across trials mean values of primary outcomes during active response phase after platform release. CG = control group; CNLBP = Chronic non-specific low back pain group; UI = Uncontrolled Manifold Index; CEA = 95% confidence ellipse surface area; ApEn = approximate entropy of antero-posterior centre of pressure signal.
Fig 5. Group comparison of variance components.
Fig 5. Group comparison of variance components.
Across trials mean variance components during the first second of the active response phase after platform release. CG = control group; CNLBP = Chronic non-specific low back pain group.
Fig 6. Group comparison of segmental angle…
Fig 6. Group comparison of segmental angle excursions.
Distribution of the angle excursions of the investigated segments with highest PCA loading. Across trial average values computed for the first second of the active response phase. *P < .025; **P < .001.

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