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Do patients with chronic low back pain have proprioceptive deficits in their lumbar spine?

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Introduction

Do patients with chronic low back pain have proprioceptive deficits in their lumbar spine? Investigators: Jennifer Winter, Chanda Mistry, Karen Barker Key words: proprioception, back pain, balance, visual feedback, joint position sense Abstract Study Design A clinical trial comparing proprioceptive awareness with and without visual feedback combined with repositioning error in ten patients with chronic low back pain. Objectives To investigate whether patients with chronic low back pain have proprioceptive deficits in the lumbar spine. Summary of Background Data Research has discovered that injuries to peripheral joints have resulted in proprioceptive deficits. As proprioception is a complex function, it is difficult to measure accurately but research suggests this is also true in the lumbar spine. This study examines two aspects of proprioception; the removal of vision to increase joint awareness and repositioning error. Indications of proprioceptive deficits should lead to rehabilitation programs incorporating proprioceptive training. Methods Sway path and sway area were measured in standing using the balance performance monitor with eyes open and eyes closed for thirty seconds. To measure repositioning error, markers were placed on C7, T10 and L4 and the patients were instructed to lean forward to touch a target board. Measurements of the marker's positions were measured before and after repositioning. Sway area, sway path and percentage mean balance was also collected before and after repositioning. Results Sway path and sway area were significantly greater when the patient's vision was removed. (sway area p<0.007, sway path p<0.005). No significant difference was found in repositioning error. Conclusions By removing vision, joint awareness becomes challenged in patients with chronic low back pain. Lumbar spine proprioception is difficult to measure in standing due to afferent input from the lower limb joints and the method employed for measuring repositioning error may not have been sensitive enough to detect significant changes. Research needs to focus on finding a valid piece of equipment to measure lumbar spine proprioception accurately along with studies to examine the effectiveness of proprioceptive rehabilitation programmes. ...read more.

Middle

The same test was used for repositioning error and was calculated via the SPSS computer software, where the alpha level was set at p<0.05. This test was used as the data is non parametric and related. Spearmans Rho was used as a correlation test between ODI and sway area with eyes closed with the p value set at the same alpha level. Fig 1 Example patient for experiment two Results The results for the eyes open / eyes closed test are summarised in Table two. As hypothesised the sway area significantly increased with eyes closed (p<0.007) as did the sway path (p<0.005) using the Wilcoxon paired significance test with a p value of p<0.05. Table three summarises the means and standard deviations of percentage mean balance (weight distribution), sway area and sway path before and after repositioning. As shown, there was not a statistical significance between these measurements before and after repositioning. The mean balance does not give a true reflection as seen in Fig two where it is clear that on repositioning, each patient alters their stance and centre of pressure. Both sway area and sway path increase on repositioning and it appears that these patients have an increased sway area compared to sway path. Repositioning error of C7, T10 and L4 is shown in Table Four but all measurements were insignificant, C7 being p<0.796, T10 p<0.230 and L4 p<0.167 using the Wilcoxon paired significance test with a p value of p<0.05. Fig three examines the relationship between sway area with eyes closed compared to the patients Oswestry Disability Index. Spearmans Rho correlation test was used with the same p value. The correlation coefficient was 0.419 and was therefore insignificant with a p value of p<0.301. Table Two Sway area and sway path results for eyes open/closed No Condition Mean SD P value 10 SAEO (mm�) 204 376.96 0.007 SAEC (mm�) 1017.8 1809.52 SPEO (mm) ...read more.

Conclusion

also confirming an increase in postural sway in low back pain patients, however the BPM is used in practice and therefore more clinically relevant. The BPM cannot measure joint position but has been deemed a valid piece of equipment by Haas et al (2000) when looking at symmetry, but not necessarily when looking at the steadiness aspect of postural control. It has been recognised as being reliable (Haas et al, 1998, Hinman et al, 1997) but they recommend that the mean of three measurements be taken to increase the reliability. Due to time constraints this was not feasible in this study. It should also be noted that Hinman (1997) and Haas (1998) studies' were carried out on healthy participants and therefore caution should be taken when generalising to the patient population. The BPM has been used as an adjunct to physiotherapy for retraining of balance for stroke patients and has been found effective in providing feedback by Sackley (1992,1993), which offers support for its clinical use. Although this is a small study it provides interesting background to CLBP and proprioception. It suggests that proprioceptive deficits do exist but perhaps more so in some patients. This may be due to certain low back dysfunctions but as diagnosis of certain conditions is difficult to reach, assessments of each patient should be taken individually and a program devised specifically, incorporating proprioceptive exercises as appropriate. This study has its limitations in terms of its sample size and quality of research and therefore provides a starting point for further research. Research looking at integrating visual feedback for training purposes would be beneficial to determine its clinical use along with continued research into finding the best method for measuring proprioception. Conclusion Proprioceptive deficits have been identified in patients with CLBP. This has been significantly shown by a decrease in joint position sense when vision is removed in standing. Although statistically insignificant, repositioning error is seen in the lumbar spine and prompts further research into this area to find a suitable method to measure proprioception and whether specific proprioceptive training is beneficial to patients with CLBP. ...read more.

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