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Purpose: To investigate coronal plane trunk asymmetry (TA) and its association with sagittal postural alignment in healthy subjects before pubertal peak growth., Methods: In this cross-sectional baseline study, 1190 healthy pre-peak growth velocity subjects were included. Coronal plane TA was evaluated using back surface topography. Whole-body sagittal alignment (previously validated and objectively classified as neutral, sway-back or leaning-forward) and sagittal spinopelvic profile (trunk lean, lumbar lordosis, thoracic kyphosis, sacral inclination and length of the posteriorly inclined thoracolumbar segment) were determined, as were height, proportion of trunk to body length, body mass index, generalized joint laxity, and handedness., Results: Logistic regression analysis yielded overall sagittal posture class to be independently associated with coronal plane TA: having a leaning-forward posture associated with a nearly three times higher odds of coronal TA (p < 0.001) compared to neutrals. A sway-back was 2.2 times more likely to show TA (p = 0.016) than a neutral, yet only in boys. Significant associations with coronal TA were also found for trunk lean, thoracic kyphosis and body mass index. These correlations, however, were gender and posture class specific. The spinal region where asymmetry is seen, varies according to the whole-body sagittal alignment type: primary thoracic curves were the most frequent in leaning-forwards, whereas primary curves in the lumbar or declive thoracolumbar segment were the most common in sway-backs., Conclusions: In immature spines without known scoliosis, coronal plane TA is associated with whole-body sagittal alignment. It is more often seen in non-neutral than neutral sagittal posture types. Whether adolescent idiopathic scoliosis is related with postural characteristics before pubertal growth peak, should be addressed in future prospective studies.

Purpose: To investigate the factors related to the 1-month period prevalence of low back pain (LBP), neck pain (NP) and thoracic spine pain (TSP) in young adolescents, thereby considering potential correlates from the physical, sociodemographic, lifestyle, psychosocial and comorbid pain domains., Methods: In this cross-sectional baseline study, 69 factors potentially associated with spinal pain were assessed among 842 healthy adolescents before pubertal peak growth. With consideration for possible sex differences in associations, multivariable analysis was used to simultaneously evaluate contributions of all variables collected in the five domains., Results: A significantly higher odds of LBP was shown for having high levels of psychosomatic complaints (odds ratio: 4.4; 95 % confidence interval: 1.6-11.9), a high lumbar lordotic apex, retroversed pelvis, introverted personality, and high levels of negative over positive affect. Associations with a higher prevalence and odds of NP were found for psychosomatic complaints (7.8; 2.5-23.9), TSP in the last month (4.9; 2.2-10.8), backward trunk lean, high levels of negative over positive affect and depressed mood. Having experienced LBP (2.7; 1.3-5.7) or NP (5.5; 2.6-11.8) in the preceding month was associated with a higher odds of TSP, as were low self-esteem, excessive physical activity, sedentarism and not achieving the Fit-norm., Conclusions: Psychosomatic symptoms and pain comorbidities had the strongest association with 1-month period prevalence of spinal pain in young adolescents, followed by factors from the physical and psychosocial domains. The role that "physical factors" play in non-adult spinal pain may have been underestimated by previous studies.

Purpose: Recent work showed an increased risk of cervical and lumbar intervertebral disc (IVD) herniations in astronauts. The European Space Agency asked the authors to advise on the underlying pathophysiology of this increased risk, to identify predisposing factors and possible interventions and to suggest research priorities., Methods: The authors performed a narrative literature review of the possible mechanisms, and conducted a survey within the team to prioritize research and prevention approaches., Results and Conclusions: Based on literature review the most likely cause for lumbar IVD herniations was concluded to be swelling of the IVD in the unloaded condition during spaceflight. For the cervical IVDs, the knowledge base is too limited to postulate a likely mechanism or recommend approaches for prevention. Basic research on the impact of (un)loading on the cervical IVD and translational research is needed. The highest priority prevention approach for the lumbar spine was post-flight care avoiding activities involving spinal flexion, followed by passive spinal loading in spaceflight and exercises to reduce IVD hyper-hydration post-flight.

Background/purpose: Measurement and classification of standing posture in the sagittal plane has important clinical implications for adolescent spinal disorders. Previous work using cluster analysis on three gross body segment orientation parameters (lower limbs, trunk, and entire body inclination) has identified three distinct postural groups of healthy subjects before pubertal peak growth: "neutral", "sway-back", and "leaning-forward". Although accurate postural subgrouping may be proposed to be crucial in understanding biomechanical challenges posed by usual standing, there is currently no objective method available for class assignment. Hence, this paper introduces a novel approach to subclassify new cases objectively according to their overall sagittal balance., Methods: Postural data previously acquired from 1,196 pre-peak height velocity (pre-PHV) subjects were used in this study. To derive a classification rule for assigning a class label ("neutral", "sway-back", or "leaning-forward") to any new pre-PHV subjects, linear discriminant analysis was applied. Predictor variables were pelvic displacement, trunk lean and body lean angle. The performance of the newly developed classification algorithm was verified by adopting a cross-validation procedure., Results: The statistical model correctly classified over 96.2% of original grouped subjects. In the cross-validation procedure used, over 95.9% of subjects were correctly assigned., Conclusions: Based on three angular measures describing gross body segment orientation, our triage method is capable of reliably classifying pre-PHV subjects as either "neutral", "sway-back", or "leaning-forward". The discriminant prediction equations presented here enable a highly accurate posture class allocation of new cases with a prediction capability higher than 95.9%, thereby removing subjectivity from sagittal plane posture classification.

Purpose: The purpose of this cohort study was to classify sagittal standing alignment of pre-peak height velocity (pre-PHV) girls, and to evaluate whether identified subgroups were associated with measures of spinal pain. This study further aimed at drawing attention to similarities and differences between the current postural classification and a previous system determined among pre-PHV boys., Methods: 557 pre-PHV girls [mean age, 10.6 years (SD, 0.47 years)] participated in the study. Three gross body segment orientation parameters and five specific lumbopelvic characteristics were quantified during habitual standing. Postural subgroups were determined by cluster analysis. Logistic regression was applied to assess the relationship between postural subgroups and spinal pain measures (pain and seeking care, assessed by self-administered questionnaire). Chi-square statistics, independent samples T test, and distribution-based methods were used for comparison with postural categorization in pre-PHV boys., Results and Conclusion: Among pre-PHV girls, clinically meaningful posture clusters emerged both on the gross body segment and specific lumbopelvic level. The postural subtypes identified among pre-PHV girls closely corresponded to those previously described in pre-PHV boys, thereby allowing the use of the same, working nomenclature. In contrast to previous findings among pre-PHV boys, no associations between posture clusters and spinal pain measures were significant in girls at pre-PHV age. When comparing discrete 'global' alignment scores across corresponding posture types, some intriguing differences were found between genders which might involve different biomechanical loading patterns. Whether habitual posture forms a risk factor for developing spinal pain up to adulthood needs evaluation in prospective multifactorial follow-up research.

Introduction: From a clinical point of view, knowledge of customary standing positions among healthy young adolescents is of primary importance. The purpose of this study was to document the correlations between sagittal standing posture parameters in a pre-peak height velocity (pre-PHV) cohort., Materials and Methods: This cohort study included 639 pre-PHV boys (age 12.6 [SD, 0.54] years) and 557 pre-PHV girls (age 10.6 [SD, 0.47] years). Gross body segment orientations and spinopelvic orientation/shape indexes were quantified using a clinical screening protocol. Pearson's correlation coefficients were determined for all sagittal standing plane alignment parameters, and a postural model was used to analyze the correlations between parameters., Results: Both at the gross body segment and spinopelvic level, an interdependence was found between postural parameters. No correlations were observed between 'global' parameters related to the pelvis, trunk or body anteroposterior translation postures and 'local' spinopelvic geometries. A similar pattern and strength of correlations was obtained in pre-PHV boys and girls, except for the reciprocal relationships between the craniovertebral angle and adjacent anatomic segment characteristics and between thoraco-lumbar geometries., Conclusions: Although the correlation schemes do not imply a causal relationship, the proposed postural model allows conjecture about standing posture to be organized slightly differently in pre-PHV boys and girls. Whereas the standing posture in pre-PHV boys might be organized predominantly according to an ascending mode, bottom-up and top-down organizations appear to coexist in pre-PHV girls.

The purpose of this study was to investigate the long-term effectiveness of a spine care education programme conducted in 9- to 11-year-old schoolchildren. The study sample included 96 intervention subjects and 98 controls (9- to 11-year-olds at baseline). Intervention consisted of a 6-week school-based back education programme (predominantly biomechanically oriented) and was implemented by a physical therapist. Self-reported outcomes on back care knowledge, spinal care behaviour, self-efficacy towards favourable back care behaviour, prevalence of back and neck pain during the week and fear-avoidance beliefs were evaluated by the use of questionnaires. Post-tests were performed within 1 week after programme completion, after 1 year and after 8 years. Whereas the educational back care programme resulted in increased back care knowledge up to adulthood (P < 0.001), intervention did not change spinal care behaviour or self-efficacy. Pain prevalence figures increased less in the experimental group compared to the controls over the 8-year time span, yet statistical significance was not reached. Dropout analysis revealed spinal pain prevalence rates to be different in both groups throughout the study, including at baseline. Back education at young age did not reinforce fear-avoidance beliefs up to adulthood. Predominantly biomechanical oriented back education in elementary schoolchildren is effective in improving the cognitive aspect of back care up to adulthood, yet not in changing actual behaviour or self-efficacy. The current study does not provide evidence that educational back care programmes have any impact on spinal pain in adulthood. The true long-term impact of school-based spinal health interventions on clinically relevant outcome measures merits further attention.

The purpose of this study was to investigate the differentiation in muscle tissue characteristics and recruitment between the deep and superficial multifidus muscle by magnetic resonance imaging. The multifidus is a very complex muscle in which a superficial and deep component can be differentiated from an anatomical, biomechanical, histological and neuromotorial point of view. To date, the histological evidence is limited to low back pain patients undergoing surgery and cadavers. The multifidus muscles of 15 healthy subjects were investigated with muscle functional MRI. Images were taken under three different conditions: (1) rest, (2) activity without pain and (3) activity after experimentally induced low back muscle pain. The T2 relaxation time in rest and the shift in T2 relaxation time after activity were compared for the deep and superficial samples of the multifidus. At rest, the T2 relaxation time of the deep portion was significantly higher compared to the superficial portion. Following exercise, there was no significant difference in shift in T2 relaxation time between the deep and superficial portions, and in the pain or in the non-pain condition. In conclusion, this study demonstrates a higher T2 relaxation time in the deep portion, which supports the current assumption that the deep multifidus has a higher percentage of slow twitch fibers compared to the superficial multifidus. No differential recruitment has been found following trunk extension with and without pain induction. For further research, it would be interesting to investigate a clinical LBP population, using this non-invasive muscle functional MRI approach.

All muscles of the neck have a role in motion and postural control of the cervical region. The aim of this study was to investigate the difference in muscle/fat index between (1) cervical flexors and extensors and (2) deep and superficial neck muscles. Twenty-six healthy subjects participated in the study. Magnetic resonance imaging (MRI) was used to quantify muscle fat indices in different cervical flexor and extensor muscles at the C4-C5 level. Overall, the ventral muscles had a significantly lower fat content compared with the dorsal muscles (P < or = 0.001). For the cervical extensors, significant differences between the muscle/fat index of the deep and superficial muscles were found (P < or = 0.001). For the cervical flexors, there were no significant differences between the different muscles. The higher fat content in the dorsal muscles can be explained by a discrepancy in function between the spine extensors and flexors, reflected in a different muscle fiber distribution. The rather small differences between superficial and deep neck muscles are in line with recent findings that have demonstrated that both muscles groups exhibit phasic activity during isometric muscles contractions and the presumption that there is no difference in fiber type distribution between superficial and deep neck muscles.

The possible effects of back education on children's back function were never evaluated. Therefore, main aim of the present study was to evaluate the effects of back education in elementary schoolchildren on back function parameters. Since the reliability of back function measurement in children is poorly defined, another objective was to test the selected instruments for reliability in 8-11-year olds. The multi-factorial intervention lasting two school-years consisted of a back education program and the stimulation of postural dynamism in the class. Trunk muscle endurance, leg muscle capacity and spinal curvature were evaluated in a pre-post design including 41 children who received the back education program (mean age at post-test: 11.2 +/- 0.9 years) and 28 controls (mean age at post-test: 11.4 +/- 0.6 years). Besides, test-retest reliability with a 1-week interval was investigated in a separate sample. Therefore, 47 children (mean age: 10.1 +/- 0.5 years) were tested for reliability of trunk muscle endurance and 40 children (mean age: 10.2 +/- 0.7 years) for the assessment of spinal curvatures. Reliability of endurance testing was very good to good for the trunk flexors (ICC = 0.82) and trunk extensors (ICC = 0.63). The assessment of the thoracic (ICC = 0.69) and the lumbar curvature (ICC = 0.52) in seating position showed good to acceptable reliability. Low ICCs were found for the assessment of the thoracic (ICC = 0.39) and the lumbar curvature (ICC = 0.37) in stance. The effects of 2 year back education showed an increase in trunk flexor endurance in the intervention group compared to a decrease in the controls and a trend towards significance for a higher increase in trunk extensor endurance in the intervention group. For leg muscle capacity and spinal curvature no intervention effects were found. The small samples recommend cautious interpretation of intervention effects. However, the present study's findings favor the implementation of back education with focus on postural dynamism in the class as an integral part of the elementary school curriculum in the scope of optimizing spinal loading through the school environment.

Work related neck disorders are common problems in office workers, especially among those who are intensive computer users. It is generally agreed that the etiology of work related neck disorders is multidimensional which is associated with, and influenced by, a complex array of individual, physical and psychosocial factors. The aim of the current study was to estimate the one-year prevalence of neck pain among office workers and to determine which physical, psychological and individual factors are associated with these prevalences. Five hundred and twelve office workers were studied. Information was collected by an online questionnaire. Self-reported neck pain during the preceding 12 months was regarded as a dependent variable, whereas different individual, work-related physical and psychosocial factors were studied as independent variables. The 12 month prevalences of neck pain in office workers was 45.5%. Multivariate analysis revealed that women had an almost two-fold risk compared with men (OR = 1.95, 95% CI 1.22-3.13). The odds ratio for age indicates that persons older than 30 years have 2.61 times more chance of having neck pain than younger individuals (OR = 2.61, 95% CI 1.32-3.47). Being physically active decreases the likelihood of having neck pain (OR = 1.85, 95% CI 1.14-2.99). Significant associations were found between neck pain and often holding the neck in a forward bent posture for a prolonged time (OR = 2.01, 95% CI 1.20-3.38), often sitting for a prolonged time (OR = 2.06, 95% CI 1.17-3.62) and often making the same movements per minute (OR = 1.63, 95% CI 1.02-2.60). Mental tiredness at the end of the workday (OR = 2.05, 95% CI 1.29-3.26) and shortage of personnel (OR = 1.71, 95% CI 1.06-2.76) are significantly associated with neck pain. The results of this study indicate that physical and psychosocial work factors, as well as individual variables, are associated with the frequency of neck pain. These association patterns suggest also opportunities for intervention strategies in order to stimulate an ergonomic work place setting and increase a positive psychosocial work environment.

Main Problem: Previous studies have demonstrated that sciatica patients have poorer postural control than healthy controls and that postural control remains unchanged 3 months after lumbar discectomy in sciatica patients. The aims of the current study were to investigate whether static balance control recovers in pain-free discectomy patients long-term after lumbar discectomy. Next is to determine whether static balance responses of asymptomatic and symptomatic lumbar discectomy patients differed from each other and from healthy controls. In addition, the influence of the extent of disc resection (unilateral/bilateral removal) and the side of operation on static balance control were investigated., Methods: Fifteen pain-free lumbar discectomy patients, 23 lumbar discectomy patients with residual pain and 72 controls performed unilateral stance tasks with eyes open and eyes closed on a force plate were taken up for the investigation. Three repetitions of a 10 s unilateral stance test were performed on each leg. Postural sway was determined. Patients were divided into three age groups., Results: In the eyes open condition, there was no significant difference between postural sway of pain-free lumbar discectomy patients and controls (P=0.68), whereas balance of patients with pain was significantly worse than in controls (P=0.003). In the eyes closed condition, the sway in both groups of lumbar discectomy patients was significantly worse than in controls (pain-free P=0.009/painful P<0.001). No significant differences were found in postural sway between patients with unilateral and bilateral disc resection. In unilateral stance on the leg of the operated side, centre of gravity sway was not significantly different in the eyes open condition compared to the eyes closed condition, whereas in stance on the leg of the non-operated side, postural sway was significantly lower in the eyes open condition compared to the eyes closed condition. In both conditions, postural sway in the age group of 50-65 years was significantly higher than in the age groups of 30-39 years (eyes open P=0.005; eyes closed P<0.001) and 40-49 years (eyes open P=0.002; eyes closed P=0.006). There was no significant difference between the age group of 30-39 years and the age group of 40-49 years (P=0.51)., Conclusion: As for long-term following lumbar discectomy, there is no complete recovery of postural control. Patients seem to develop visual compensation mechanisms for underlying sensory-motor deficits, which are, however, sufficient in case of pain relief only. Further study is needed to determine the cause of the balance disturbances in lumbar discectomy patients.

The present study was carried out to examine possible mechanisms of back muscle dysfunction by assessing a stabilising and a torque-producing back muscle, the multifidus (MF) and the iliocostalis lumborum pars thoracis (ICLT), respectively, in order to identify whether back pain patients showed altered recruitment patterns during different types of exercise. In a group of healthy subjects (n=77) and patients with sub-acute (n=24) and chronic (51) low back pain, the normalised electromyographic (EMG) activity of the MF and the ICLT (as a percentage of maximal voluntary contraction) were analysed during coordination, stabilisation and strength exercises. The results showed that, in comparison with the healthy subjects, the chronic low back pain patients displayed significantly lower (P=0.013) EMG activity of the MF during the coordination exercises, indicating that, over the long term, back pain patients have a reduced capacity to voluntarily recruit the MF in order to obtain a neutral lordosis. In contrast, during the stabilisation exercises, no significant differences between patients and controls were found for the normalised EMG activity of the two muscles. These findings indicated that, during low-load exercises, no insufficiencies in back muscle recruitment were evident in either subacute or chronic back pain patients. During the strength exercises, the normalised activity of both back muscles was significantly lower in chronic low back pain patients (P=0.017 and 0.003 for the MF and ICLT, respectively) than in healthy controls. Pain, pain avoidance and deconditioning may have contributed to these lower levels of EMG activity during intensive back muscle contraction. The possible dysfunction of the MF during coordination exercises and the altered activity of both muscles during strength exercises may be of importance in symptom generation, recurrence or maintenance of low back pain.

Increasing documentation on the size and appearance of muscles in the lumbar spine of low back pain (LBP) patients is available in the literature. However, a comparative study between unoperated chronic low back pain (CLBP) patients and matched (age, gender, physical activity, height and weight) healthy controls with regard to muscle cross-sectional area (CSA) and the amount of fat deposits at different levels has never been undertaken. Moreover, since a recent focus in the physiotherapy management of patients with LBP has been the specific training of the stabilizing muscles, there is a need for quantifying and qualifying the multifidus. A comparative study between unoperated CLBP patients and matched control subjects was conducted. Twenty-three healthy volunteers and 32 patients were studied. The muscle and fat CSAs were derived from standard computed tomography (CT) images at three different levels, using computerized image analysis techniques. The muscles studied were: the total paraspinal muscle mass, the isolated multifidus and the psoas. The results showed that only the CSA of the multifidus and only at the lowest level (lower end-plate of L4) was found to be statistically smaller in LBP patients. As regards amount of fat, in none of the three studied muscles was a significant difference found between the two groups. An aetiological relationship between atrophy of the multifidus and the occurrence of LBP can not be ruled out as a possible explanation. Alternatively, atrophy may be the consequence of LBP: after the onset of pain and possible long-loop inhibition of the multifidus a combination of reflex inhibition and substitution patterns of the trunk muscles may work together and could cause a selective atrophy of the multifidus. Since this muscle is considered important for lumbar segmental stability, the phenomenon of atrophy may be a reason for the high recurrence rate of LBP.