Tim Mitchell

Regional differences in lumbar spinal posture and the influence of low back pain

BackgroundSpinal posture is commonly a focus in the assessment and clinical management of low back pain (LBP) patients. However, the link between spinal posture and LBP is not fully understood. Recent evidence suggests that considering regional, rather than total lumbar spine posture is important. The purpose of this study was to determine; if there are regional differences in habitual lumbar spine posture and movement, and if these findings are influenced by LBP.MethodsOne hundred and seventy female undergraduate nursing students, with and without LBP, participated in this cross-sectional study. Lower lumbar (LLx), Upper lumbar (ULx) and total lumbar (TLx) spine angles were measured using an electromagnetic tracking system in static postures and across a range of functional tasks.ResultsRegional differences in lumbar posture and movement were found. Mean LLx posture did not correlate with ULx posture in sitting (r = 0.036, p = 0.638), but showed a moderate inverse correlation with ULx posture in usual standing (r = -0.505, p < 0.001). Regional differences in range of motion from reference postures in sitting and standing were evident. BMI accounted for regional differences found in all sitting and some standing measures. LBP was not associated with differences in regional lumbar spine angles or range of motion, with the exception of maximal backward bending range of motion (F = 5.18, p = 0.007).ConclusionThis study supports the concept of regional differences within the lumbar spine during common postures and movements. Global lumbar spine kinematics do not reflect regional lumbar spine kinematics, which has implications for interpretation of measures of spinal posture, motion and loading. BMI influenced regional lumbar posture and movement, possibly representing adaptation due to load.

Low back pain characteristics from undergraduate student to working nurse in Australia: A cross-sectional survey

BACKGROUND Nurses are known to be a high risk group for occupational low back pain (LBP). The periods of greatest risk for developing low back pain in this population are not well defined. Recent literature suggests current preventative strategies are not consistently effective in improving low back injury statistics among health care populations. OBJECTIVES To identify the relative contributions of age and occupational exposure on the prevalence, duration and severity of low back pain episodes among undergraduate nursing students and recently graduated nurses. DESIGN Cross-sectional survey. SETTINGS Two university undergraduate nursing schools and one public teaching hospital graduate nurse training program in Western Australia. PARTICIPANTS 897 undergraduate nursing students (years 1, 2 and 3) and 111 graduate nurses recruited by personal invitation during lectures. METHODS Using a modified version of the Nordic Low Back Questionnaire, information regarding low back pain episode prevalence, impact, duration, frequency and causes was obtained. RESULTS Mean age was consistent across all groups (26.7+/-9.0 years) and had no significant effect on lifetime low back pain prevalence (p=0.30). Very high lifetime (79%), 12 month (71%) and 7 day (31%) low back pain prevalence rates were consistent across all 3 year groups of undergraduate nursing students, but were significantly higher after 12 months of full-time employment [lifetime (95.5%), 12 month (90%) and 7 day (39%)]. Around 60% of all respondents with low back pain utilised at least one of (a) treatment, (b) medication, or (c) a reduction in activity. Nursing students and graduate nurses attributed the majority of their low back pain to bending or lifting despite recent efforts to reduce manual workplace demands (lifting) on nurses. Strategies for managing low back pain differed between nursing students and graduate nurses. CONCLUSIONS These results may suggest a rise in occupational exposure from student to working nurse is the primary cause of the increase in low back pain. Increased exposure may be to physical as well as psychological stressors. Given that prevalence rates are very high prior to commencing work, nursing student populations should be a target group for low back pain preventative strategies.

Identification of modifiable personal factors that predict new-onset low back pain: a prospective study of female nursing students.

ObjectivesPrevention of occupational low back pain (LBP) in nurses is a research priority. Recent research suggests intervening before commencing nursing employment is ideal; however, identification of modifiable risk factors is required. The objective of this study was to investigate modifiable personal characteristics that predicted new-onset LBP in nursing students. MethodsThis prospective study was conducted on female nursing students (n=117) without LBP at baseline to predict new-onset LBP (an episode of significant LBP during the follow-up period). At the 12-month follow-up, participants with (n=31) and without new-onset LBP (n=76) were compared across baseline social or lifestyle, psychologic (distress, back pain beliefs, coping strategies, and catastrophising), and physical (spinal postures and spinal kinematics in functional tasks, leg and back muscle endurance, spinal repositioning error, and cardiovascular fitness) characteristics. ResultsParticipants response rate at follow-up was excellent (91%). After controlling for earlier LBP, age, and BMI, regression analysis showed that modifiable social or lifestyle, psychologic and physical characteristics (namely, smoking, increased physical activity, higher stress, reduced back muscle endurance, greater posterior pelvic rotation in slump sitting, and more accurate spinal repositioning in sitting) were significant and independent predictors of new-onset LBP at follow-up. Inclusion of these factors in multivariate logistic regression analysis, with significant new-onset LBP as the outcome, resulted in a substantial model R2 of 0.45. DiscussionModifiable personal characteristics across multiple domains are associated with new-onset LBP in female nursing students. These findings may have implications for the development of prevention and management interventions for LBP in nurses.

Effect of subject restraint and resistance pad placement on isokinetic knee flexor and extensor strength: implications for testing and rehabilitation.

Background: In clinical practice, several subject restraint and resistance pad placement variations are used when an isokinetic knee flexion/extension test is performed. However, it is unknown if these variations affect the outcome measures. The aims of this study were to determine if these setup variations affect isokinetic outcomes and to establish the smallest detectable difference for these setup variations. Hypothesis: Variation in isokinetic setup affects outcome measures. Study Design: Cross-sectional repeated-measures crossover study. Methods: Ten recreationally active adult men were examined with isokinetic dynamometry on 4 separate days. In the first 3 days, fully strapped and trunk-unstrapped testing was conducted with the resistance pad placed distally on the shin. On days 1 and 3, the unstrapped condition was performed first, followed by the strapped condition. On day 4, the resistance pad was placed proximal on the shin (anterior cruciate ligament testing). Results: There were no within-condition differences for days 1, 2, or 3 for the strapped and unstrapped conditions (P > 0.05). Between-condition comparisons were significant (eg, quadriceps peak torque, P < 0.001; hamstring peak torque, P = 0.043) for the strapped, unstrapped, and proximal resistance pad placement conditions. The strapped condition generally showed the largest torques, and the unstrapped, the least. The smallest detectable differences were relatively large (eg, quadriceps peak torque strapped = 20.6%). The greatest intraclass correlation values were found when strapped. Conclusions: Subject setup significantly influences isokinetic outcome measures at the knee. Since the strapped condition demonstrated the greatest repeatability, it is recommended. The smallest detectable differences were relatively high for all variables and should be considered in the interpretation of the effect size of interventions. Clinical Relevance: Subject setup strapping must be considered when investigating test-retest values or when comparing subjects after isokinetic testing at the knee. The fully strapped condition has the best repeatability and highest torque values.

Rising trends in surgery for rotator cuff disease in Western Australia

Increasing rates of surgery for rotator cuff disease have been reported in the past decade in a number of countries worldwide. Rising surgery rates do not correspond with equivalent increases in shoulder pain prevalence. The aims of the study were: to investigate trends in population‐adjusted surgical rates for rotator cuff disease in Western Australia (WA) from 2001 to 2013; to compare population‐adjusted arthroscopic surgical trends between (i) private versus public hospital setting; (ii) sex and (iii) different age groups; and to evaluate rising health care costs associated with arthroscopic surgical rates for rotator cuff disease.

Adaptations at the shoulder of the throwing athlete and implications for the clinician

The shoulders of those involved in repeated forceful overhead throwing undergo a range of neural, muscular, and skeletal adaptations. Knowledge of these normal adaptations may be helpful for the understanding of the prevention and treatment of injury in these athletes. This paper summarizes the current literature regarding these adaptations, and their relation to performance and pathology are presented along with relevant clinical implications. Throwing athletes show alterations in the strength ratio of their internal rotation (IR) compared with external rotation such that IR is enhanced and external rotation remains unchanged (in comparison with their nonthrowing arm). Typical scapular postural changes are seen (often IR and anterior tilting of the scapula) in the throwing arm; the humeral cortical and trabecular bones are thickened and there is often greater humeral retrotorsion. Torsional changes are, however, variable. Throwers have a higher incidence of injury to their suprascapular nerve, which may help explain their relative external rotational weakness. There is some evidence that the posterior inferior capsule is thickened in throwing athletes.

Rotator cuff disease: Opinion regarding surgical criteria and likely outcome

Clinical guidelines for the management of rotator cuff disease are not clear. Surgeon surveys in the USA and UK lack agreement regarding surgical indications. Physical examination tests aid surgical decision‐making but also lack robust evidence. Study aims were to evaluate: Western Australian orthopaedic surgeons’ perceptions about surgical indications; utility of physical examination tests; findings at surgery predictive of outcome and surgeon opinion of a successful surgical outcome.

Characterisation of pain in people with hereditary neuropathy with liability to pressure palsy

Hereditary neuropathy with liability to pressure palsy (HNPP) has historically been considered a pain-free condition, though some people with HNPP also complain of pain. This study characterised persistent pain in people with HNPP. Participants provided cross-sectional demographic data, information on the presence of neurological and persistent pain symptoms, and the degree to which these interfered with daily life. The painDETECT and Central Sensitization Inventory questionnaires were used to indicate potential neuropathic, central sensitisation and musculoskeletal (nociceptive) pain mechanisms. Additionally, participants were asked if they thought that pain was related to/part of HNPP. 32/43 (74%) subjects with HNPP had persistent pain and experience this pain in the last week. Of those with pain, 24 (75%) were likely to have neuropathic pain and 27 (84%) were likely to have central sensitisation. All 32 participants felt that their pain could be related to/part of their HNPP. Significant negative impact of the pain was common. Pain characterisation identified neuropathic pain and/or central sensitisation as common, potential underlying processes. Pain may plausibly be directly related to the underlying pathophysiology of HNPP. Further consideration of including pain as a primary symptom of HNPP is warranted.