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Lower limb kinematics in individuals with chronic low back pain during walking
Journal Pre-proofs Lower Limb Kinematics in Individuals with Chronic Low Back Pain during Walking Atefeh Rahimi, Amir Masoud Arab, Mohammad Reza Nourbakhsh, Sayed Mohsen Hosseini, Saeed Forghany PII: DOI: Reference:
S1050-6411(20)30019-5 https://doi.org/10.1016/j.jelekin.2020.102404 JJEK 102404
To appear in:
Journal of Electromyography and Kinesiology
Received Date: Revised Date: Accepted Date:
6 August 2019 8 December 2019 12 February 2020
Please cite this article as: A. Rahimi, A. Masoud Arab, M. Reza Nourbakhsh, S. Mohsen Hosseini, S. Forghany, Lower Limb Kinematics in Individuals with Chronic Low Back Pain during Walking, Journal of Electromyography and Kinesiology (2020), doi: https://doi.org/10.1016/j.jelekin.2020.102404
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Lower Limb Kinematics in Individuals with Chronic Low Back Pain during Walking
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Atefeh Rahimi , Amir Masoud Arab ,*, Mohammad Reza Nourbakhsh b, , Sayed Mohsen Hosseini c, Saeed Forghany d, e
ᵃ Department of Physical therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran ᵇ Department of Physical therapy, University of North Georgia, Dahlonega, USA Epidemiology and Biostatistics Department, Health Faulty, Isfahan University of Medical sciences, Isfahan, Iran d Musculoskeletal Research Centre, School of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, Iran e School
of Health Sciences, University of Salford, Salford, UK
* Corresponding author. Tel.: 09122069111- University of Social Welfare and Rehabilitation Sciences, Department of Physical therapy E-mail addresses: [email protected] Email Addresses:
[email protected]( Atefeh Rahimi), [email protected](Amir Masoud Arab), [email protected] (Mohammad Reza Nourbakhsh), [email protected] (Sayed Mohsen Hosseini), [email protected] (Saeed Forghany),
Abstract Several investigators have suggested the presence of a link between Chronic Low Back Pain (CLBP) and lower limbs kinematics that can contribute to functional limitations and disability. Moreover, CLBP has been connected to postural and structural asymmetry. Understanding the movement pattern of lower extremities and its asymmetry during walking can provide a basis for examination and rehabilitation in people with CLBP. The present study focuses on lower limbs kinematics in individuals with CLBP during walking. Three-dimensional movements of the pelvic, hip, knee and ankle joints were tracked using a seven-camera Qualysis motion capture system. Functional dada analysis (FDA) was applied for the
statistical analysis of pelvic and lower limbs motion patterns in 40 participants (20 CLBP and 20 controls). The CLBP group showed significantly different hip motion pattern in the transvers plane, altered knee and ankle motion pattern in the sagittal plane on the dominant side and different hip motion pattern in the transvers and frontal planes on the non-dominant side in comparison with the control group over the stance phase. In terms of symmetry, in the CLBP group, hip and knee moved through a significantly different motion patterns in the transvers plane on the dominant side in comparison with the non-dominant side. In the control group, knee moved through a significantly different motion pattern in the transvers plane on the dominant side in comparison with the non-dominant side. In conclusion, low back pain lead to altered movement patterns of the main joints of lower limbs especially on the dominant side during stance phase. Therefore, care should be taken to examine dominant lower limb movement pattern in CLBP to make a better clinical decision. Keywords: Low Back Pain, Kinematics, walking, pelvic, hip, knee, ankle
Introduction
Introduction Chronic Low back pain (CLBP) is a common musculoskeletal disorder, which affects more than 80% of people in their lives. However, in 57-89 percent of people with CLBP, no specific etiology can be identified (Andersson 1999). Clinical evidence suggests that individuals with CLBP suffer from different forms of lower limb movement impairments, which may lead to development and persistence of LBP-related problems (McGregor and Hukins 2009). However, the nature and degrees of these impairments and their association with CLBP are relatively unexplored.
Most literature focuses on clinical examinations, typically conducted during static positions like sitting, lying down or forward bending. People with CLBP experience less hip internal and external rotations and less hip extension in prone position (Roach, San Juan et al. 2015, Sadeghisani, Manshadi et al. 2015) and less pelvic posterior tilt during sitting and forward bending (Lim, Roh et al. 2013); Brantingham et al. suggested that these people display less sagittal plane ankle range of motion (ROM) in the standing position compared to healthy participants (Brantingham, Gilbert et al. 2007). Evidence about dynamic types of movement abnormalities, especially during walking and in frontal and transverse planes is sparse.
The spine has been modeled as an inverted pendulum in which a slender column supports the load of the upper body (Meakin, Hukins et al. 1996, Peter Reeves, Narendra et al. 2007, Zeinali-Davarani, Hemami et al. 2008). This inverted pendulum requires a shifting base to maintain its stability, which is the pelvis bone and lower limbs (Peter Reeves, Narendra et al. 2007, Zeinali-Davarani, Hemami et al. 2008). Therefore, the pelvic-lower limb complex is an important kinematic chain for the spine (Sadeghisani, Manshadi et al. 2015).
The pelvic, hip, knee, and ankle complex includes multiple segments and joint mechanisms, which influence the interaction between the low back complex and lower limb during locomotion. Any disorder affecting either of these complexes can alter this interaction and may result in abnormal locomotion. Therefore, biomechanical studies of the lower limb complex during walking are needed to understand the pathology of movement disorders following CLBP, their impact on patient locomotion, and the potential treatments.
Different types of gait impairments such as short stride length and rigid coordination between trunk segments have been reported in people with CLBP (Lamoth, Beek et al. 2002, Lamoth, Meijer et al. 2002, Lamoth, Daffertshofer et al. 2004). Findings related to pelvic and lower limb kinematics yield controversial issues. Some studies have reported that people with LBP display no differences in the pelvic kinematic during walking (Vogt, Pfeifer et al. 2001) or less pelvic rotation in the transvers plane (Lamoth, Meijer et al. 2002, Seay Jr 2008, Seay, Van Emmerik et al. 2011, Müller, Ertelt et al. 2015), while others have reported a greater degree of pelvic rotation in this plane (Kuai, Zhou et al. 2017).
Vogt et al found that hip flexion during walking in the CLBP is less than healthy subjects (Vogt, Pfeifer et al. 2003), whereas, Kuai et al found no differences in hip motion (Kuai, Zhou et al. 2017). Moreover, there is controversy about the knee joint kinematics during walking. Kuai et al. found no significant change in knee kinematics of men with lumbar disc herniation (Müller, Ertelt et al. 2015, Kuai, Zhou et al. 2017). However, Muller et al. suggested that people with CLBP experience more extension at the knee joint at the time of heel strike (HS) (Müller, Ertelt et al. 2015). Therefore, the first aim of this study was to investigate pelvic and lower limb kinematics in people with CLBP.
Additionally, clinical examinations during static conditions such as standing, sitting, and lying position demonstrated pelvic and trunk asymmetric motion and significant differences between
dominant and non-dominant lower limbs in people with CLBP (Egan and Al-Eisa 1999, Tawfik 2001, Al-Eisa, Egan et al. 2006, Van Dillen, Bloom et al. 2008). These asymmetries can alter the body mechanics, put various body segments under strain, and cause impaired movement patterns. Hence, it is advised that assessment of lower limbs asymmetry be part of the movement and postural evaluation undertaken by health professionals when treating patients with musculoskeletal problems (Al-Eisa, Egan et al. 2004).
In the few gait analysis studies that have paid attention to lower limb asymmetry post LBP, some have involved certain types of LBP such as participants with radicular pain (Janura, Gallo et al. 2015), others have only studied limited parameters of walking such as temporospatial features (Sung and Danial 2017). The data from such studies could be misleading as they do not reflect the complex multi-segmental movements that occur in the lower limb during walking in CLBP. It was further hypothesized that lower limb kinematics differs between the dominant and non-dominant sides in people with LBP, and therefore, the second purpose of this study was to investigate the asymmetry in pelvic and lower limb kinematics during walking in individuals with CLBP.
Materials and Methods Study Participant The study participants included 20 people with CLBP (10 men with 38.25 ± 8.7 years of age, height of 168.35 ± 8.8cm and weight of 65.87 ± 8.75 kg) and 20 healthy individuals (10 men with 36.35 ± 4.5 years of age, height of 170.65 ± 9.0 cm, and weight of 66.6 ± 8.29 kg). Ethical approval was obtained from University of Social Welfare and Rehabilitation ethics committee. The inclusion criteria for the LBP participants consisted of a medical diagnosis of nonspecific LBP, pain and symptoms persisting for longer than 3 months, 18-65 years of age, and ambulation without a walking aid. Participants were excluded if they had LBP as a result of traumatic or structural conditions, LBP
with neurological symptoms or pain radiation in the lower extremities, spinal tumors or infections, and other neurological and/or musculoskeletal disorder unrelated to LBP. The inclusion criteria for the healthy participants included lack of any visible motor dysfunctions, lack of history of lower extremity injuries, lack of any types of surgery in the past 6 months, lack of any types of back pain, and lack of any intense exercises during the 24 hours before the trial.
Procedure A seven camera Qualysis Proreflex system was used to obtain the three-dimensional (3D) coordinate kinematic data of the lower limbs. This system is based on infra-red (IR) camera technology and passive retro-reflective markers using Qualisys Track Manager Software (version 2.7, Qualisys AB, Gothenburg, Sweden) at a frequency of 100 Hz.
Retro reflective markers were placed to track the motion of the pelvis, hip, knee, and ankle. The anatomic markers on the pelvis were placed on the left posterior superior iliac spine, right posterior superior iliac spine right anterior superior iliac spine, and left anterior superior iliac spine. The anatomic markers on the lower extremities were placed on the right and left greater trochanter, right and left epicondyle, right and left malleolus, right and left calcaneus, and right and left first and fifth metatarsal head. Four rigid bodies with four fixed markers were strapped to the right and left thigh and shank.
A four segmental lower limb biomechanical model was defined including pelvis, thigh, shank and foot. Each segment was modeled as a single rigid segment. According to the position of anatomical markers within every segment during static trial (CAST technique), segment coordinate systems (SCSs) and anatomical planes were constructed for each segment.
In this study, the kinematics involved the average of 5 trials of walking across a 7-meter walkway for every participant. The participants were instructed to direct their attention straight ahead and not to target the pathway test. All participants were given adequate rest time between trials in order to minimize the effect of fatigue.
The foot velocity algorithm (FVA) method was used to determine the gait events. It is a simple method which accurately and automatically determines initial contact (IC) and toe off (TO) according to the features in the vertical velocity of the foot center derived from the trajectories of the heel and toe markers. This vertical velocity has a simple characteristic shape repeated for each gait cycle with easily identifiable features (peaks and troughs) taking place at IC and TO. TO is detected at the local maximum peaks and IC is the second minimum peak after TO (O'Connor, Thorpe et al. 2007). A stance phase was defined as the time between IC to TO of the same leg.
Data Processing Three dimensional joint rotations were calculated according to the joint coordinate system (JCS). JCS is established based on the two SCSs. Two axes of the JCS are fixed within segments and a third axis is floating and defined as perpendicular to each of the two fixed segment axes (Grood and Suntay 1983).
Kinematics data exported from Qualysis system processed using Visual3d software (C-motion, USA) to characterize the movement patterns of segments over the time. Markers data were smoothed first using a 4th order Butterworth low-pass filter with a cut off frequency of 6 and 15 Hz, respectively. A pre-defined 10 frames gap fill was set up where interpolation was undertaken using a cubic spline algorithm. The typical gap size was between 2 and 5 frames in our data.
Kinematic data were normalized to 100 percent of stance phase to enable ensemble averaging across trials. Kinematic data was recalculated with respect to the relaxed standing position, (in common with most kinematic studies) (Leardini, Benedetti et al. 1999, Hunt, Smith et al. 2001, Lundgren, Nester et al. 2008) so that 0º was the position of all joints during relaxed standing.
Statistical analysis Shapiro-Wilk statistics was employed to check the normality of distribution of data. All data conformed to a
normal distribution. In the current study, we have applied the functional data analysis statistical approach for analyzing data collected over time. It is the same technique as the Principal Component Analysis (PCA) but, instead of doing it with variables, the FDA does it with functions. This allows representing any function as a linear combination of a set of curves extracted statistically from the set of curves. All computations were done in MATLAB, R-package named SCBmeanfd. Result The present study results showed no statistically significant differences between the CLBP and control groups in terms of speed, stride length, age, height, weight and BMI (Table 1). Table 2 and 3 display the P-value and graph for the pelvis, hip, knee, and ankle in the sagittal, frontal and transvers planes.
Pelvis Group comparison: Pelvic motion patterns of the CLBP were similar to that of the control group in the three planes during the stance phase.
Hip Group comparison: On the dominant side, the CLBP group showed a significantly different hip transverse motion pattern over the stance time compared to the control group(F= 50.22, P= 0.00);
graph observation showed a less externally rotated hip during early stance and a less internally rotated hip over the late stance time. On the non-dominant side, the CLBP group showed a significantly different patterns of hip transvers and frontal motion over the stance time compared to the control group; graph observation showed a less externally rotated (F= 22.52, P= 0.01) and abducted hip throughout the stance phase (F= 55.26, P= 0.047). Symmetry: In terms of symmetry analysis in the CLBP group, the only significant difference between the dominant and the non-dominant sides was observed in the pattern of hip transverse motion throughout the stance phase (F= 34.23, P= 0.01). Observation showed a less externally rotated hip during the early stance and a less internally rotated hip over the late stance on the dominant side in comparison with the non-dominant side. In the control group, no significant differences were observed between the dominant and non-dominant hip rotations in all three planes.
Knee Group comparison: On the dominant side, CLBP group showed a significantly different pattern of knee sagittal motion over the stance time compared to the control group; graph observation showed a less flexed knee during late stance (F= 35.30, P= 0.01). On the non-dominant side, there were no significant differences between the CLBP and control groups. Symmetry: In terms of symmetry analysis in both the CLBP and control group, the only significant difference between the dominant and the non-dominant sides was observed in the pattern of knee transverse motion throughout the stance phase; graph observation in the CLBP group, showed a less internally rotated knee during the stance (F= 37.89, P= 0.003). In the control group, the dominant side showed a less externally rotated knee over the stance phase in comparison with the non-dominant side. (F= 22.27, P=0.02)
Ankle Group comparison: On the dominant side, the CLBP group showed a significantly different pattern of ankle sagittal motion over the stance time compared to the control group; graph observation showed a more plantar flexed ankle during the early stance and a less dorsi flexed ankle over the late stance time (F= 2.73, P= 0.03). On the non-dominant side, there were no significant differences between the CLBP and the control groups. Symmetry: In terms of symmetry analysis in both the CLBP and control groups, there were similar patterns of ankle motion for the dominant and non-dominant sides in all three planes.
Discussion
The present study was carried out with the aim to evaluate the kinematics of the pelvic and lower extremities in patients with CLBP during walking. To our knowledge, this is the first kinematic study investigating lower limbs kinematic patterns rather than investigating only special discrete values. Prior gait studies of lower limb kinematics in people with LBP have only reported discrete values such as Range of Motion (ROM), angle at IC and TO between CLBP and healthy individuals. These values provide an incomplete picture of the problems because, as data only at the certain points of time is considered (Vogt, Pfeifer et al. 2001, Vogt, Pfeifer et al. 2003, Müller, Ertelt et al. 2015, Kuai, Zhou et al. 2017, MacRae and Critchley 2018).
In the current study, pelvic and lower limbs kinematic patterns during the stance phase were studied using FDA approach by which method all data are considered rather than few data point at specific time events. More specifically, a functional data analysis can be utilized to compare condition effects on the entire period of time. In this way, a functional data analysis may be more informative, relative to other statistical approaches that analyze discrete points in time (Ullah and Finch 2013).
Our findings show that, in the CLBP group, hip kinematic patterns of dominant side in the frontal and transverse planes were different from healthy subjects. In such a way that hip moved through a less externally rotated and abducted position in the early stance phase and a less internally rotated and abducted in the late stance. Marshall et al and Cooper et al reported that people with CLBP suffer from weakness of gluteal muscles and hip rotators which could be the most possible explanation for our findings of abnormal kinematic pattern of hip joint (Marshall, Patel et al. 2011, Cooper, Scavo et al. 2016).
In terms of knee joint, CLBP group showed different knee flexion pattern in the sagittal plane. Knee moved through a less flexed position in the late stance which according to Marshall et al findings may be due to hamstring weakness (Marshall, Mannion et al. 2010). Ankle moved through a more plantarflexed position in the early stance and less dorsiflexed position in the late stance in comparison with control group. This is in accordance with the report of increased stiffness of plantrflexors in people with CLBP (Vadivelan, Poyyamozhi et al. 2017). Also, altered knee and ankle movement patterns in the sagittal plane may be a compensatory strategy to avoid displacement of the center of gravity in downward direction and reduce mechanical load on low back (Marshall, Mannion et al. 2010, Zahraee, Karimi et al. 2014, Vadivelan, Poyyamozhi et al. 2017).
Abnormal brain structure and function such as maladaptive brain plasticity in the motor controlrelated areas has been reported in people with CLBP. (Flor, Braun et al. 1997, Tsao, Galea et al. 2008, Tsao, Danneels et al. 2011, Masse-Alarie, Flamand et al. 2012), In people with CLBP, changes in the motor control of the lumbar region have been reported to be associated with motor control impairments in the pelvis and lower extremities (Leung, Mendis et al. 2015, Sheikhhoseini, Alizadeh et al. 2018). In fact, according to the concept of “pain and neuronal plasticity”, prolonged musculoskeletal pain syndromes might contribute to alterations of dynamic motor stereotypes and motor regulation and present specific movement patterns of the trunk, pelvis or lower limb. This may
be a possible explanation for the changes observed in the lower limbs movement patterns in the CLBP in the current study.
Our study reports for the first time, the symmetry of lower limb kinematic patterns during walking. In people with CLBP, hip rotation pattern in the transvers plane was different. On the dominant side hip moved through a less externally rotated position in the early stance and a less internally rotated in the late stance in comparison with the non-dominant side. In addition, knee rotation pattern in the transvers plane showed a less internally rotated position through the entire stance phase on the dominant side in comparison with the non-dominant side. Based on previous studies, in people with CLBP, ground reaction force on the dominant side is less than non-dominant side which could explain the observed asymmetries in the present study(Zahraee, Karimi et al. 2014).
Most individuals have a right dominant motor and posture patterns due to physiological asymmetry (Sadeghi, Allard et al. 2000, Susan Henning 2017) which normally expected to cause changes in the kinematics and muscle activation of the trunk, pelvis and lower extremities. Research studies suggested that people with CLBP display more asymmetric movement of trunk and limbs and also asymmetric spatiotemporal parameters in comparison with healthy individuals during walking (Tawfik 2001, Al-Eisa, Egan et al. 2004, Al-Eisa, Egan et al. 2006, Van Dillen, Gombatto et al. 2007, Sung, Danial et al. 2016, Sung and Danial 2017), which indicated more asymmetric motor control (muscle activation) in individuals with CLBP than healthy people (Kim, Kwon et al. 2013, Leung, Mendis et al. 2015).
There are some limitations in the current study. The first and common limitation to most laboratory 3D gait studies is the small number of participants recruited. The second limitation is that our data only concerned on kinematic aspect of pelvic and lower limb biomechanics. Further studies are suggested to explore other potential aspects such as lower limb electromyography and muscle activation patterns during
walking. There is potential for clinical studies to developments of interventions to prevent or treat these impairments and biomechanical abnormalities, with the ultimate of improving function and quality of life for the CLBP population.
Conclusion Chronic low back pain leads to change in movement patterns of hip, knee and ankle on the dominant side during the stance phase of walking. Therefore, care should be taken to assess the walking patterns of lower limb joints in CLBP to facilitate motion depending on the patient’s presentation.
Conflict of interest None declared. Acknowledgement We would like to acknowledge the valuable advice given by Professor Mohamad Parnianpour (Sharif University of Technology, Department of Mechanical Engineering) on data processing.
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Seay Jr, J. F. (2008). Lumbo-sacral loads and pelvis-trunk coordination in runners with chronic and resolved acute low back pain, ProQuest. Sheikhhoseini, R., M.-H. Alizadeh, M. Salavati, K. O'Sullivan, E. Shirzad and M. Movahed (2018). "Altered lower limb kinematics during jumping among athletes with persistent low back pain." Annals of Applied Sport Science: 0-0. Sung, P. S. and P. Danial (2017). "A Kinematic Symmetry Index of Gait Pattern Between Older Adults with and without Low Back Pain." Spine (Phila Pa 1976). Sung, P. S., P. Danial and D. C. Lee (2016). "Comparison of the different kinematic patterns during lateral bending between subjects with and without recurrent low back pain." Clinical Biomechanics 38: 50-55. Susan Henning, L. C. M. a. J. M. (2017). "Postural Restoration: A Tri-Planar Asymmetrical Framework for Understanding, Assessing, and TreatingScoliosis and Other Spinal Dysfunctions." Advance Physical Therapy. Tawfik, B. (2001). "Symmetry and linearity of trunk function in subjects with non-specific low back pain." Clin Biomech (Bristol, Avon) 16(2): 114-120. Tsao, H., L. A. Danneels and P. W. Hodges (2011). "ISSLS prize winner: Smudging the motor brain in young adults with recurrent low back pain." Spine (Phila Pa 1976) 36(21): 1721-1727. Tsao, H., M. P. Galea and P. W. Hodges (2008). "Reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain." Brain 131(Pt 8): 2161-2171. Ullah, S. and C. F. Finch (2013). "Applications of functional data analysis: A systematic review." BMC medical research methodology 13(1): 43. Vadivelan, K., J. Poyyamozhi, G. D. Kumar and C. R. Rushender (2017). "Comparison of active calf muscle stretching versus ankle mobilisation on low back pain and lumbar flexibility in pronated foot subjects." International Journal Of Community Medicine And Public Health 4(6): 1870-1875. Van Dillen, L. R., N. J. Bloom, S. P. Gombatto and T. M. Susco (2008). "Hip rotation range of motion in people with and without low back pain who participate in rotation-related sports." Physical Therapy in Sport 9(2): 72-81. Van Dillen, L. R., S. P. Gombatto, D. R. Collins, J. R. Engsberg and S. A. Sahrmann (2007). "Symmetry of timing of hip and lumbopelvic rotation motion in 2 different subgroups of people with low back pain." Archives of physical medicine and rehabilitation 88(3): 351-360. Vogt, L., K. Pfeifer and W. Banzer (2003). "Neuromuscular control of walking with chronic low-back pain." Manual therapy 8(1): 21-28. Vogt, L., K. Pfeifer, M. Portscher and W. Banzer (2001). "Influences of nonspecific low back pain on three-dimensional lumbar spine kinematics in locomotion." Spine 26(17): 1910-1919. Zahraee, M. H., M. T. Karimi, J. Mostamand and F. Fatoye (2014). "Analysis of asymmetry of the forces applied on the lower limb in subjects with nonspecific chronic low back pain." BioMed research international 2014. Zeinali-Davarani, S., H. Hemami, K. Barin, A. Shirazi-Adl and M. Parnianpour (2008). "Dynamic stability of spine using stability-based optimization and muscle spindle reflex." IEEE Transactions on Neural Systems and Rehabilitation Engineering 16(1): 106-118.
Age
Height
Weight
BMI
Speed
Stride
(years)
(cm)
(Kg)
(Kg/m2)
(m/cm)
Length (m)
CLBP
38.25 ± 8.7
168.35 ± 8.8
65.87 ± 8.75
23.47 ± 2.03
1.29 ± 0.43
0.29 ± 0.21
Control
36.35 ± 4.5
170.65 ± 9.0
66.6 ± 8.29
22.54 ± 1.66
1.39 ± 0.43
0.21 ± 0.16
P-value
0.56
0.42
0.79
0.12
Table 1: Anthropometric data and Spatiotemporal gait parameters CLBP: Chronic lower back pain
0.35
0.23
Table 2: F, P value and kinematic curve for the pelvis, hip, knee, and ankle in the sagittal, frontal and transvers planes between two
groups. CLBP
* P value < 0.05
Control Sagittal
Frontal
10
20 1 9 17 25 33 41 49 57 65 73 81 89 97
0
0
Nondomina nt Hip
-20
1 9 17 25 33 41 49 57 65 73 81 89 97
1 9 17 25 33 41 49 57 65 73 81 89 97 -5
-10
F
P value
F
P value
F
P value
2.21
0.13
1.36
0.34
1.93
0.19
50
10
10
0
0
0 1 8 15222936435057647178859299
-10
-10
-50 F
P value
F
P value
F
P value
2.20
0.30
0.34
0.68
50.22
0.00 *
50
10
10
0
0
0
-50
1 9 17 25 33 41 49 57 65 73 81 89 97 1 9 17 25 33 41 49 57 65 73 81 89 97
Domin ant Hip
0
1 9 17 25 33 41 49 57 65 73 81 89 97 1 9 17 25 33 41 49 57 65 73 81 89 97
Pelvis
Transvers
1 7 131925313743495561677379859197 -10
-10
F
P value
F
P value
F
P value
1.39
0.93
55.26
0.048*
22.52
0.01 *
20 5
0
0
1 9 17 25 33 41 49 57 65 73 81 89 97 1 9 17 25 33 41 49 57 65 73 81 89 97
Domin ant Knee
10
1 8 15222936435057647178859299 0 -20 -5 -40
-10
-60 F 35.30
-20 Nondomina nt Knee
F 0.75
P value 0.58
F 1.62
5 1 7 131925313743495561677379859197
20
0
0
-40
-5
P value 0.29
1 9 17 25 33 41 49 57 65 73 81 89 97 1 9 17 25 33 41 49 57 65 73 81 89 97
0
P value 0.01 *
-20
-60 F
P value
F
P value
F
P value
1.90
0.18
0.35
0.43
1.83
0.20
20
10
0
0
0
1 9 17 25 33 41 49 57 65 73 81 89 97 1 9 17 25 33 41 49 57 65 73 81 89 97 1 9 17 25 33 41 49 57 65 73 81 89 97
Domin ant Ankle
20
F
P value
F
P value
F
P value
2.73
0.03*
1.72
0.33
1.05
0.29
20
10
20 0
0 1 7 131925313743495561677379859197 1 8 15222936435057647178859299 -20 -10
0
1 9 17 25 33 41 49 57 65 73 81 89 97
Nondomina nt Ankle
-10
-20
-20
-20 F
P value
F
P value
F
P value
0.54
0.64
1.78
0.63
2.52
0.08
Table 3: F, P value and kinematic curve for the pelvis, hip, knee, and ankle in the sagittal, frontal and transvers planes between
dominant and non-dominant sides in two groups. Non-dominant side
Dominant side
* P value < 0.05
CLBP Group Frontal
40
10
10
0
0
20
-20
1 9 17 25 33 41 49 57 65 73 81 89 97
0
-10
1 9 17 25 33 41 49 57 65 73 81 89 97
Hip
Transvers
-10
F 2.17
P value 0.09
F 1.44
P value 0.37
1 9 17 25 33 41 49 57 65 73 81 89 97
Sagittal
F 34.23
P value 0.01 *
20 20
0
5 1 7 131925313743495561677379859197 0 -20 -5
-40
-20
1 9 17 25 33 41 49 57 65 73 81 89 97
1 9 17 25 33 41 49 57 65 73 81 89 97
Knee
0
-60 P value
F
P value
F
P value
2.35
0.06
1.78
0.13
37.89
0.003 *
0
10
0
0
1 9 17 25 33 41 49 57 65 73 81 89 97
Ankle
20
-20
-20 F 1.75
P value 0.30
1 9 17 25 33 41 49 57 65 73 81 89 97
20
-10
F 0.96 Control Group
P value 0.80
1 10 19 28 37 46 55 64 73 82 91 100
F
F 1.55
P value 0.41
Hip
0 -20
10
10
0
0 1 10 19 28 37 46 55 64 73 82 91 100
20
-10 1 8 15222936435057647178859299 F 1.39
-10
P value 0.43
F 1.19
P value 0.43
1 9 17 25 33 41 49 57 65 73 81 89 97
40
F 1.73
P value 0.20
20 20
0
5 1 7 131925313743495561677379859197 0 -20
-20
1 9 17 25 33 41 49 57 65 73 81 89 97
-5
-40
0 1 9 17 25 33 41 49 57 65 73 81 89 97
Knee
-60 P value
F
P value
F
P value
2.77
0.08
1.36
0.32
22.27
0.02 *
10
0
0
0
-10
10 Ankle
1 9 17 25 33 41 49 57 65 73 81 89 97
10
1 9 17 25 33 41 49 57 65 73 81 89 97
20
-10
-10
-20
1 9 17 25 33 41 49 57 65 73 81 89 97
F
F
P value
F
P value
F
P value
1.63
0.38
0.87
0.79
1.05
0.33
Amir Massoud Arab Amir Massoud Arab Professor Department of Physical Therapy University of Welfare and Rehabilitation Sciences Iran
Biography Amir Massoud Arab is a Professor at department of physical therapy at the University of social welfare and rehabilitation sciences. He is PhD in Physical Therapy. He has published several articles in the international journals and has several presentations in different conferences. He is vice chair and director of biomechanics laboratory in physical therapy department. He is also administrator of student’s research committee at the university. He was chairman and scientific president of some national seminars. He has done several research projects in the field of spine, low back pain, pelvic floor dysfunction, movement pattern, ultrasonography and electromyography.
S1050-6411(20)30019-5 https://doi.org/10.1016/j.jelekin.2020.102404 JJEK 102404
To appear in:
Journal of Electromyography and Kinesiology
Received Date: Revised Date: Accepted Date:
6 August 2019 8 December 2019 12 February 2020
Please cite this article as: A. Rahimi, A. Masoud Arab, M. Reza Nourbakhsh, S. Mohsen Hosseini, S. Forghany, Lower Limb Kinematics in Individuals with Chronic Low Back Pain during Walking, Journal of Electromyography and Kinesiology (2020), doi: https://doi.org/10.1016/j.jelekin.2020.102404
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© 2020 Published by Elsevier Ltd.
Lower Limb Kinematics in Individuals with Chronic Low Back Pain during Walking
ᵃ
ᵃ
Atefeh Rahimi , Amir Masoud Arab ,*, Mohammad Reza Nourbakhsh b, , Sayed Mohsen Hosseini c, Saeed Forghany d, e
ᵃ Department of Physical therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran ᵇ Department of Physical therapy, University of North Georgia, Dahlonega, USA Epidemiology and Biostatistics Department, Health Faulty, Isfahan University of Medical sciences, Isfahan, Iran d Musculoskeletal Research Centre, School of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, Iran e School
of Health Sciences, University of Salford, Salford, UK
* Corresponding author. Tel.: 09122069111- University of Social Welfare and Rehabilitation Sciences, Department of Physical therapy E-mail addresses: [email protected] Email Addresses:
[email protected]( Atefeh Rahimi), [email protected](Amir Masoud Arab), [email protected] (Mohammad Reza Nourbakhsh), [email protected] (Sayed Mohsen Hosseini), [email protected] (Saeed Forghany),
Abstract Several investigators have suggested the presence of a link between Chronic Low Back Pain (CLBP) and lower limbs kinematics that can contribute to functional limitations and disability. Moreover, CLBP has been connected to postural and structural asymmetry. Understanding the movement pattern of lower extremities and its asymmetry during walking can provide a basis for examination and rehabilitation in people with CLBP. The present study focuses on lower limbs kinematics in individuals with CLBP during walking. Three-dimensional movements of the pelvic, hip, knee and ankle joints were tracked using a seven-camera Qualysis motion capture system. Functional dada analysis (FDA) was applied for the
statistical analysis of pelvic and lower limbs motion patterns in 40 participants (20 CLBP and 20 controls). The CLBP group showed significantly different hip motion pattern in the transvers plane, altered knee and ankle motion pattern in the sagittal plane on the dominant side and different hip motion pattern in the transvers and frontal planes on the non-dominant side in comparison with the control group over the stance phase. In terms of symmetry, in the CLBP group, hip and knee moved through a significantly different motion patterns in the transvers plane on the dominant side in comparison with the non-dominant side. In the control group, knee moved through a significantly different motion pattern in the transvers plane on the dominant side in comparison with the non-dominant side. In conclusion, low back pain lead to altered movement patterns of the main joints of lower limbs especially on the dominant side during stance phase. Therefore, care should be taken to examine dominant lower limb movement pattern in CLBP to make a better clinical decision. Keywords: Low Back Pain, Kinematics, walking, pelvic, hip, knee, ankle
Introduction
Introduction Chronic Low back pain (CLBP) is a common musculoskeletal disorder, which affects more than 80% of people in their lives. However, in 57-89 percent of people with CLBP, no specific etiology can be identified (Andersson 1999). Clinical evidence suggests that individuals with CLBP suffer from different forms of lower limb movement impairments, which may lead to development and persistence of LBP-related problems (McGregor and Hukins 2009). However, the nature and degrees of these impairments and their association with CLBP are relatively unexplored.
Most literature focuses on clinical examinations, typically conducted during static positions like sitting, lying down or forward bending. People with CLBP experience less hip internal and external rotations and less hip extension in prone position (Roach, San Juan et al. 2015, Sadeghisani, Manshadi et al. 2015) and less pelvic posterior tilt during sitting and forward bending (Lim, Roh et al. 2013); Brantingham et al. suggested that these people display less sagittal plane ankle range of motion (ROM) in the standing position compared to healthy participants (Brantingham, Gilbert et al. 2007). Evidence about dynamic types of movement abnormalities, especially during walking and in frontal and transverse planes is sparse.
The spine has been modeled as an inverted pendulum in which a slender column supports the load of the upper body (Meakin, Hukins et al. 1996, Peter Reeves, Narendra et al. 2007, Zeinali-Davarani, Hemami et al. 2008). This inverted pendulum requires a shifting base to maintain its stability, which is the pelvis bone and lower limbs (Peter Reeves, Narendra et al. 2007, Zeinali-Davarani, Hemami et al. 2008). Therefore, the pelvic-lower limb complex is an important kinematic chain for the spine (Sadeghisani, Manshadi et al. 2015).
The pelvic, hip, knee, and ankle complex includes multiple segments and joint mechanisms, which influence the interaction between the low back complex and lower limb during locomotion. Any disorder affecting either of these complexes can alter this interaction and may result in abnormal locomotion. Therefore, biomechanical studies of the lower limb complex during walking are needed to understand the pathology of movement disorders following CLBP, their impact on patient locomotion, and the potential treatments.
Different types of gait impairments such as short stride length and rigid coordination between trunk segments have been reported in people with CLBP (Lamoth, Beek et al. 2002, Lamoth, Meijer et al. 2002, Lamoth, Daffertshofer et al. 2004). Findings related to pelvic and lower limb kinematics yield controversial issues. Some studies have reported that people with LBP display no differences in the pelvic kinematic during walking (Vogt, Pfeifer et al. 2001) or less pelvic rotation in the transvers plane (Lamoth, Meijer et al. 2002, Seay Jr 2008, Seay, Van Emmerik et al. 2011, Müller, Ertelt et al. 2015), while others have reported a greater degree of pelvic rotation in this plane (Kuai, Zhou et al. 2017).
Vogt et al found that hip flexion during walking in the CLBP is less than healthy subjects (Vogt, Pfeifer et al. 2003), whereas, Kuai et al found no differences in hip motion (Kuai, Zhou et al. 2017). Moreover, there is controversy about the knee joint kinematics during walking. Kuai et al. found no significant change in knee kinematics of men with lumbar disc herniation (Müller, Ertelt et al. 2015, Kuai, Zhou et al. 2017). However, Muller et al. suggested that people with CLBP experience more extension at the knee joint at the time of heel strike (HS) (Müller, Ertelt et al. 2015). Therefore, the first aim of this study was to investigate pelvic and lower limb kinematics in people with CLBP.
Additionally, clinical examinations during static conditions such as standing, sitting, and lying position demonstrated pelvic and trunk asymmetric motion and significant differences between
dominant and non-dominant lower limbs in people with CLBP (Egan and Al-Eisa 1999, Tawfik 2001, Al-Eisa, Egan et al. 2006, Van Dillen, Bloom et al. 2008). These asymmetries can alter the body mechanics, put various body segments under strain, and cause impaired movement patterns. Hence, it is advised that assessment of lower limbs asymmetry be part of the movement and postural evaluation undertaken by health professionals when treating patients with musculoskeletal problems (Al-Eisa, Egan et al. 2004).
In the few gait analysis studies that have paid attention to lower limb asymmetry post LBP, some have involved certain types of LBP such as participants with radicular pain (Janura, Gallo et al. 2015), others have only studied limited parameters of walking such as temporospatial features (Sung and Danial 2017). The data from such studies could be misleading as they do not reflect the complex multi-segmental movements that occur in the lower limb during walking in CLBP. It was further hypothesized that lower limb kinematics differs between the dominant and non-dominant sides in people with LBP, and therefore, the second purpose of this study was to investigate the asymmetry in pelvic and lower limb kinematics during walking in individuals with CLBP.
Materials and Methods Study Participant The study participants included 20 people with CLBP (10 men with 38.25 ± 8.7 years of age, height of 168.35 ± 8.8cm and weight of 65.87 ± 8.75 kg) and 20 healthy individuals (10 men with 36.35 ± 4.5 years of age, height of 170.65 ± 9.0 cm, and weight of 66.6 ± 8.29 kg). Ethical approval was obtained from University of Social Welfare and Rehabilitation ethics committee. The inclusion criteria for the LBP participants consisted of a medical diagnosis of nonspecific LBP, pain and symptoms persisting for longer than 3 months, 18-65 years of age, and ambulation without a walking aid. Participants were excluded if they had LBP as a result of traumatic or structural conditions, LBP
with neurological symptoms or pain radiation in the lower extremities, spinal tumors or infections, and other neurological and/or musculoskeletal disorder unrelated to LBP. The inclusion criteria for the healthy participants included lack of any visible motor dysfunctions, lack of history of lower extremity injuries, lack of any types of surgery in the past 6 months, lack of any types of back pain, and lack of any intense exercises during the 24 hours before the trial.
Procedure A seven camera Qualysis Proreflex system was used to obtain the three-dimensional (3D) coordinate kinematic data of the lower limbs. This system is based on infra-red (IR) camera technology and passive retro-reflective markers using Qualisys Track Manager Software (version 2.7, Qualisys AB, Gothenburg, Sweden) at a frequency of 100 Hz.
Retro reflective markers were placed to track the motion of the pelvis, hip, knee, and ankle. The anatomic markers on the pelvis were placed on the left posterior superior iliac spine, right posterior superior iliac spine right anterior superior iliac spine, and left anterior superior iliac spine. The anatomic markers on the lower extremities were placed on the right and left greater trochanter, right and left epicondyle, right and left malleolus, right and left calcaneus, and right and left first and fifth metatarsal head. Four rigid bodies with four fixed markers were strapped to the right and left thigh and shank.
A four segmental lower limb biomechanical model was defined including pelvis, thigh, shank and foot. Each segment was modeled as a single rigid segment. According to the position of anatomical markers within every segment during static trial (CAST technique), segment coordinate systems (SCSs) and anatomical planes were constructed for each segment.
In this study, the kinematics involved the average of 5 trials of walking across a 7-meter walkway for every participant. The participants were instructed to direct their attention straight ahead and not to target the pathway test. All participants were given adequate rest time between trials in order to minimize the effect of fatigue.
The foot velocity algorithm (FVA) method was used to determine the gait events. It is a simple method which accurately and automatically determines initial contact (IC) and toe off (TO) according to the features in the vertical velocity of the foot center derived from the trajectories of the heel and toe markers. This vertical velocity has a simple characteristic shape repeated for each gait cycle with easily identifiable features (peaks and troughs) taking place at IC and TO. TO is detected at the local maximum peaks and IC is the second minimum peak after TO (O'Connor, Thorpe et al. 2007). A stance phase was defined as the time between IC to TO of the same leg.
Data Processing Three dimensional joint rotations were calculated according to the joint coordinate system (JCS). JCS is established based on the two SCSs. Two axes of the JCS are fixed within segments and a third axis is floating and defined as perpendicular to each of the two fixed segment axes (Grood and Suntay 1983).
Kinematics data exported from Qualysis system processed using Visual3d software (C-motion, USA) to characterize the movement patterns of segments over the time. Markers data were smoothed first using a 4th order Butterworth low-pass filter with a cut off frequency of 6 and 15 Hz, respectively. A pre-defined 10 frames gap fill was set up where interpolation was undertaken using a cubic spline algorithm. The typical gap size was between 2 and 5 frames in our data.
Kinematic data were normalized to 100 percent of stance phase to enable ensemble averaging across trials. Kinematic data was recalculated with respect to the relaxed standing position, (in common with most kinematic studies) (Leardini, Benedetti et al. 1999, Hunt, Smith et al. 2001, Lundgren, Nester et al. 2008) so that 0º was the position of all joints during relaxed standing.
Statistical analysis Shapiro-Wilk statistics was employed to check the normality of distribution of data. All data conformed to a
normal distribution. In the current study, we have applied the functional data analysis statistical approach for analyzing data collected over time. It is the same technique as the Principal Component Analysis (PCA) but, instead of doing it with variables, the FDA does it with functions. This allows representing any function as a linear combination of a set of curves extracted statistically from the set of curves. All computations were done in MATLAB, R-package named SCBmeanfd. Result The present study results showed no statistically significant differences between the CLBP and control groups in terms of speed, stride length, age, height, weight and BMI (Table 1). Table 2 and 3 display the P-value and graph for the pelvis, hip, knee, and ankle in the sagittal, frontal and transvers planes.
Pelvis Group comparison: Pelvic motion patterns of the CLBP were similar to that of the control group in the three planes during the stance phase.
Hip Group comparison: On the dominant side, the CLBP group showed a significantly different hip transverse motion pattern over the stance time compared to the control group(F= 50.22, P= 0.00);
graph observation showed a less externally rotated hip during early stance and a less internally rotated hip over the late stance time. On the non-dominant side, the CLBP group showed a significantly different patterns of hip transvers and frontal motion over the stance time compared to the control group; graph observation showed a less externally rotated (F= 22.52, P= 0.01) and abducted hip throughout the stance phase (F= 55.26, P= 0.047). Symmetry: In terms of symmetry analysis in the CLBP group, the only significant difference between the dominant and the non-dominant sides was observed in the pattern of hip transverse motion throughout the stance phase (F= 34.23, P= 0.01). Observation showed a less externally rotated hip during the early stance and a less internally rotated hip over the late stance on the dominant side in comparison with the non-dominant side. In the control group, no significant differences were observed between the dominant and non-dominant hip rotations in all three planes.
Knee Group comparison: On the dominant side, CLBP group showed a significantly different pattern of knee sagittal motion over the stance time compared to the control group; graph observation showed a less flexed knee during late stance (F= 35.30, P= 0.01). On the non-dominant side, there were no significant differences between the CLBP and control groups. Symmetry: In terms of symmetry analysis in both the CLBP and control group, the only significant difference between the dominant and the non-dominant sides was observed in the pattern of knee transverse motion throughout the stance phase; graph observation in the CLBP group, showed a less internally rotated knee during the stance (F= 37.89, P= 0.003). In the control group, the dominant side showed a less externally rotated knee over the stance phase in comparison with the non-dominant side. (F= 22.27, P=0.02)
Ankle Group comparison: On the dominant side, the CLBP group showed a significantly different pattern of ankle sagittal motion over the stance time compared to the control group; graph observation showed a more plantar flexed ankle during the early stance and a less dorsi flexed ankle over the late stance time (F= 2.73, P= 0.03). On the non-dominant side, there were no significant differences between the CLBP and the control groups. Symmetry: In terms of symmetry analysis in both the CLBP and control groups, there were similar patterns of ankle motion for the dominant and non-dominant sides in all three planes.
Discussion
The present study was carried out with the aim to evaluate the kinematics of the pelvic and lower extremities in patients with CLBP during walking. To our knowledge, this is the first kinematic study investigating lower limbs kinematic patterns rather than investigating only special discrete values. Prior gait studies of lower limb kinematics in people with LBP have only reported discrete values such as Range of Motion (ROM), angle at IC and TO between CLBP and healthy individuals. These values provide an incomplete picture of the problems because, as data only at the certain points of time is considered (Vogt, Pfeifer et al. 2001, Vogt, Pfeifer et al. 2003, Müller, Ertelt et al. 2015, Kuai, Zhou et al. 2017, MacRae and Critchley 2018).
In the current study, pelvic and lower limbs kinematic patterns during the stance phase were studied using FDA approach by which method all data are considered rather than few data point at specific time events. More specifically, a functional data analysis can be utilized to compare condition effects on the entire period of time. In this way, a functional data analysis may be more informative, relative to other statistical approaches that analyze discrete points in time (Ullah and Finch 2013).
Our findings show that, in the CLBP group, hip kinematic patterns of dominant side in the frontal and transverse planes were different from healthy subjects. In such a way that hip moved through a less externally rotated and abducted position in the early stance phase and a less internally rotated and abducted in the late stance. Marshall et al and Cooper et al reported that people with CLBP suffer from weakness of gluteal muscles and hip rotators which could be the most possible explanation for our findings of abnormal kinematic pattern of hip joint (Marshall, Patel et al. 2011, Cooper, Scavo et al. 2016).
In terms of knee joint, CLBP group showed different knee flexion pattern in the sagittal plane. Knee moved through a less flexed position in the late stance which according to Marshall et al findings may be due to hamstring weakness (Marshall, Mannion et al. 2010). Ankle moved through a more plantarflexed position in the early stance and less dorsiflexed position in the late stance in comparison with control group. This is in accordance with the report of increased stiffness of plantrflexors in people with CLBP (Vadivelan, Poyyamozhi et al. 2017). Also, altered knee and ankle movement patterns in the sagittal plane may be a compensatory strategy to avoid displacement of the center of gravity in downward direction and reduce mechanical load on low back (Marshall, Mannion et al. 2010, Zahraee, Karimi et al. 2014, Vadivelan, Poyyamozhi et al. 2017).
Abnormal brain structure and function such as maladaptive brain plasticity in the motor controlrelated areas has been reported in people with CLBP. (Flor, Braun et al. 1997, Tsao, Galea et al. 2008, Tsao, Danneels et al. 2011, Masse-Alarie, Flamand et al. 2012), In people with CLBP, changes in the motor control of the lumbar region have been reported to be associated with motor control impairments in the pelvis and lower extremities (Leung, Mendis et al. 2015, Sheikhhoseini, Alizadeh et al. 2018). In fact, according to the concept of “pain and neuronal plasticity”, prolonged musculoskeletal pain syndromes might contribute to alterations of dynamic motor stereotypes and motor regulation and present specific movement patterns of the trunk, pelvis or lower limb. This may
be a possible explanation for the changes observed in the lower limbs movement patterns in the CLBP in the current study.
Our study reports for the first time, the symmetry of lower limb kinematic patterns during walking. In people with CLBP, hip rotation pattern in the transvers plane was different. On the dominant side hip moved through a less externally rotated position in the early stance and a less internally rotated in the late stance in comparison with the non-dominant side. In addition, knee rotation pattern in the transvers plane showed a less internally rotated position through the entire stance phase on the dominant side in comparison with the non-dominant side. Based on previous studies, in people with CLBP, ground reaction force on the dominant side is less than non-dominant side which could explain the observed asymmetries in the present study(Zahraee, Karimi et al. 2014).
Most individuals have a right dominant motor and posture patterns due to physiological asymmetry (Sadeghi, Allard et al. 2000, Susan Henning 2017) which normally expected to cause changes in the kinematics and muscle activation of the trunk, pelvis and lower extremities. Research studies suggested that people with CLBP display more asymmetric movement of trunk and limbs and also asymmetric spatiotemporal parameters in comparison with healthy individuals during walking (Tawfik 2001, Al-Eisa, Egan et al. 2004, Al-Eisa, Egan et al. 2006, Van Dillen, Gombatto et al. 2007, Sung, Danial et al. 2016, Sung and Danial 2017), which indicated more asymmetric motor control (muscle activation) in individuals with CLBP than healthy people (Kim, Kwon et al. 2013, Leung, Mendis et al. 2015).
There are some limitations in the current study. The first and common limitation to most laboratory 3D gait studies is the small number of participants recruited. The second limitation is that our data only concerned on kinematic aspect of pelvic and lower limb biomechanics. Further studies are suggested to explore other potential aspects such as lower limb electromyography and muscle activation patterns during
walking. There is potential for clinical studies to developments of interventions to prevent or treat these impairments and biomechanical abnormalities, with the ultimate of improving function and quality of life for the CLBP population.
Conclusion Chronic low back pain leads to change in movement patterns of hip, knee and ankle on the dominant side during the stance phase of walking. Therefore, care should be taken to assess the walking patterns of lower limb joints in CLBP to facilitate motion depending on the patient’s presentation.
Conflict of interest None declared. Acknowledgement We would like to acknowledge the valuable advice given by Professor Mohamad Parnianpour (Sharif University of Technology, Department of Mechanical Engineering) on data processing.
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Age
Height
Weight
BMI
Speed
Stride
(years)
(cm)
(Kg)
(Kg/m2)
(m/cm)
Length (m)
CLBP
38.25 ± 8.7
168.35 ± 8.8
65.87 ± 8.75
23.47 ± 2.03
1.29 ± 0.43
0.29 ± 0.21
Control
36.35 ± 4.5
170.65 ± 9.0
66.6 ± 8.29
22.54 ± 1.66
1.39 ± 0.43
0.21 ± 0.16
P-value
0.56
0.42
0.79
0.12
Table 1: Anthropometric data and Spatiotemporal gait parameters CLBP: Chronic lower back pain
0.35
0.23
Table 2: F, P value and kinematic curve for the pelvis, hip, knee, and ankle in the sagittal, frontal and transvers planes between two
groups. CLBP
* P value < 0.05
Control Sagittal
Frontal
10
20 1 9 17 25 33 41 49 57 65 73 81 89 97
0
0
Nondomina nt Hip
-20
1 9 17 25 33 41 49 57 65 73 81 89 97
1 9 17 25 33 41 49 57 65 73 81 89 97 -5
-10
F
P value
F
P value
F
P value
2.21
0.13
1.36
0.34
1.93
0.19
50
10
10
0
0
0 1 8 15222936435057647178859299
-10
-10
-50 F
P value
F
P value
F
P value
2.20
0.30
0.34
0.68
50.22
0.00 *
50
10
10
0
0
0
-50
1 9 17 25 33 41 49 57 65 73 81 89 97 1 9 17 25 33 41 49 57 65 73 81 89 97
Domin ant Hip
0
1 9 17 25 33 41 49 57 65 73 81 89 97 1 9 17 25 33 41 49 57 65 73 81 89 97
Pelvis
Transvers
1 7 131925313743495561677379859197 -10
-10
F
P value
F
P value
F
P value
1.39
0.93
55.26
0.048*
22.52
0.01 *
20 5
0
0
1 9 17 25 33 41 49 57 65 73 81 89 97 1 9 17 25 33 41 49 57 65 73 81 89 97
Domin ant Knee
10
1 8 15222936435057647178859299 0 -20 -5 -40
-10
-60 F 35.30
-20 Nondomina nt Knee
F 0.75
P value 0.58
F 1.62
5 1 7 131925313743495561677379859197
20
0
0
-40
-5
P value 0.29
1 9 17 25 33 41 49 57 65 73 81 89 97 1 9 17 25 33 41 49 57 65 73 81 89 97
0
P value 0.01 *
-20
-60 F
P value
F
P value
F
P value
1.90
0.18
0.35
0.43
1.83
0.20
20
10
0
0
0
1 9 17 25 33 41 49 57 65 73 81 89 97 1 9 17 25 33 41 49 57 65 73 81 89 97 1 9 17 25 33 41 49 57 65 73 81 89 97
Domin ant Ankle
20
F
P value
F
P value
F
P value
2.73
0.03*
1.72
0.33
1.05
0.29
20
10
20 0
0 1 7 131925313743495561677379859197 1 8 15222936435057647178859299 -20 -10
0
1 9 17 25 33 41 49 57 65 73 81 89 97
Nondomina nt Ankle
-10
-20
-20
-20 F
P value
F
P value
F
P value
0.54
0.64
1.78
0.63
2.52
0.08
Table 3: F, P value and kinematic curve for the pelvis, hip, knee, and ankle in the sagittal, frontal and transvers planes between
dominant and non-dominant sides in two groups. Non-dominant side
Dominant side
* P value < 0.05
CLBP Group Frontal
40
10
10
0
0
20
-20
1 9 17 25 33 41 49 57 65 73 81 89 97
0
-10
1 9 17 25 33 41 49 57 65 73 81 89 97
Hip
Transvers
-10
F 2.17
P value 0.09
F 1.44
P value 0.37
1 9 17 25 33 41 49 57 65 73 81 89 97
Sagittal
F 34.23
P value 0.01 *
20 20
0
5 1 7 131925313743495561677379859197 0 -20 -5
-40
-20
1 9 17 25 33 41 49 57 65 73 81 89 97
1 9 17 25 33 41 49 57 65 73 81 89 97
Knee
0
-60 P value
F
P value
F
P value
2.35
0.06
1.78
0.13
37.89
0.003 *
0
10
0
0
1 9 17 25 33 41 49 57 65 73 81 89 97
Ankle
20
-20
-20 F 1.75
P value 0.30
1 9 17 25 33 41 49 57 65 73 81 89 97
20
-10
F 0.96 Control Group
P value 0.80
1 10 19 28 37 46 55 64 73 82 91 100
F
F 1.55
P value 0.41
Hip
0 -20
10
10
0
0 1 10 19 28 37 46 55 64 73 82 91 100
20
-10 1 8 15222936435057647178859299 F 1.39
-10
P value 0.43
F 1.19
P value 0.43
1 9 17 25 33 41 49 57 65 73 81 89 97
40
F 1.73
P value 0.20
20 20
0
5 1 7 131925313743495561677379859197 0 -20
-20
1 9 17 25 33 41 49 57 65 73 81 89 97
-5
-40
0 1 9 17 25 33 41 49 57 65 73 81 89 97
Knee
-60 P value
F
P value
F
P value
2.77
0.08
1.36
0.32
22.27
0.02 *
10
0
0
0
-10
10 Ankle
1 9 17 25 33 41 49 57 65 73 81 89 97
10
1 9 17 25 33 41 49 57 65 73 81 89 97
20
-10
-10
-20
1 9 17 25 33 41 49 57 65 73 81 89 97
F
F
P value
F
P value
F
P value
1.63
0.38
0.87
0.79
1.05
0.33
Amir Massoud Arab Amir Massoud Arab Professor Department of Physical Therapy University of Welfare and Rehabilitation Sciences Iran
Biography Amir Massoud Arab is a Professor at department of physical therapy at the University of social welfare and rehabilitation sciences. He is PhD in Physical Therapy. He has published several articles in the international journals and has several presentations in different conferences. He is vice chair and director of biomechanics laboratory in physical therapy department. He is also administrator of student’s research committee at the university. He was chairman and scientific president of some national seminars. He has done several research projects in the field of spine, low back pain, pelvic floor dysfunction, movement pattern, ultrasonography and electromyography.