Archives of Physical Medicine and Rehabilitation
Volume 91, Issue 9 , Pages 1327-1331, September 2010

Comparison of Trunk Proprioception Between Patients With Low Back Pain and Healthy Controls

  • Angela S. Lee, BS

      Affiliations

    • Michigan State University Center for Orthopedic Research, Department of Osteopathic Surgical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI
    • ,
  • Jacek Cholewicki, PhD

      Affiliations

    • Michigan State University Center for Orthopedic Research, Department of Osteopathic Surgical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI
    • Corresponding Author InformationReprint requests to Jacek Cholewicki, MSU Center for Orthopedic Research, Ingham Regional Orthopedic Hospital, 2727 S Pennsylvania Ave, Lansing, MI 48910
    • ,
  • N. Peter Reeves, PhD

      Affiliations

    • Michigan State University Center for Orthopedic Research, Department of Osteopathic Surgical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI
    • ,
  • Bohdanna T. Zazulak, DPT

      Affiliations

    • Department of Orthopaedics and Rehabilitation, Yale-New Haven Hospital/Yale University School of Medicine, New Haven, CT
    • ,
  • Lawrence W. Mysliwiec, DO

      Affiliations

    • Michigan State University Center for Orthopedic Research, Department of Osteopathic Surgical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI

Article Outline

Abstract 

Lee AS, Cholewicki J, Reeves NP, Zazulak BT, Mysliwiec LW. Comparison of trunk proprioception between patients with low back pain and healthy controls.

Objective

To determine whether proprioceptive impairments exist in patients with low back pain (LBP). We hypothesized that patients with LBP would exhibit larger trunk proprioception errors than healthy controls.

Design

Case-control study.

Setting

University laboratory.

Participants

24 patients with nonspecific LBP and 24 age-matched healthy controls.

Interventions

Not applicable.

Main Outcome Measures

We measured trunk proprioception in all 3 anatomical planes using motion perception threshold, active repositioning, and passive repositioning tests.

Results

LBP patients had significantly greater motion perception threshold than controls (P<.001) (1.3±0.9° vs 0.8±0.6°). Furthermore, all subjects had the largest motion perception threshold in the transverse plane (P<.001) (1.2±0.7° vs 1.0±0.8° for all other planes averaged). There was no significant difference between LBP and healthy control groups in the repositioning tasks. Errors in the active repositioning test were significantly smaller than in the passive repositioning test (P=.032) (1.9±1.2° vs 2.3±1.4°).

Conclusions

These findings suggest that impairments in proprioception may be detected in patients with LBP when assessed with a motion perception threshold measure.

Key Words: Kinesthesis, Low back pain, Proprioception, Rehabilitation, Spine

List of Abbreviations: ICC, intraclass correlation coefficient, LBP, low back pain

 

PROPRIOCEPTION IS “the sense of position and movement of one's own limbs and body without using vision. There are two submodalities of proprioception: the sense of the stationary position of the limbs (limb-position sense) and the sense of limb movement (kinesthesia).”1(p443) The ability to sense stationary position and movement is an important aspect of executing body motion.2 Proprioceptive signals, as one of the sensory modalities, are obtained from mechanoreceptors imbedded in ligaments, facet joints, intervertebral disks, and muscles.3, 4, 5, 6 Among these sources, dense muscle spindles in paraspinal rotators are thought to be crucial for monitoring the midrange motion of the trunk.7, 8, 9 Because ability to monitor trunk motion is necessary to generate movement pattern, any deficit in proprioception would affect the quality of movement.

For chronic LBP patients, differences in motor control, such as longer muscle reflex latencies,10, 11, 12, 13 poor postural control,11, 14, 15, 16, 17, 18, 19, 20 and altered muscle recruitment patterns,21, 22, 23, 24, 25 have been documented. These differences in motor control could be, in part, attributed to deficits in proprioception. Proprioception has been studied in LBP using various protocols, and the outcomes of these studies vary. Some studies have found proprioceptive impairment associated with LBP,9, 26, 27, 28, 29, 30, 31 whereas others have found no impairments.32, 33, 34, 35, 36 These conflicting results could stem from diversity in the LBP population28, 30, 31 and/or different testing methods.34, 37

The variation in methodologies includes different testing positions (standing,27, 32, 34 sitting,28 or 4-point kneeling27) and different measurement methods (trunk repositioning task27, 32, 33, 34, 35 or motion perception threshold29, 36). Within-session repeatability of various measurement methods showed that motion perception threshold had the highest intraclass correlation (ICC=0.89) compared to active and passive repositioning tests (ICC=0.61 and ICC=0.58, respectively).36 Motion perception threshold represents a person's sensitivity to a small change in trunk position. Other tests, such as active repositioning and passive repositioning, rely on memory to recall the starting or other prescribed positions. The memory recall issue may increase variability and errors.38, 39

Furthermore, studies assessed proprioception in different planes of motion29, 32, 33, 34, 36 and measured either trunk rotations29, 36 or translations.28 Thus, despite the large number of studies published on proprioception and LBP, no clear conclusions can be reached about a possible impairment in LBP patients.

The goal of this study was to determine whether proprioception impairments are associated with LBP in any of the 3 anatomical planes (sagittal, coronal, and transverse). We also hypothesized that proprioceptive impairments, should they exist, would be detected with the more sensitive motion perception threshold test, but not with repositioning tests.

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Methods 

Subjects 

Twenty-four subjects with LBP (11 males and 13 females) and 24 healthy controls without a history of LBP (14 males and 10 females) volunteered for the study. Of the 24 LBP subjects, 9 (5 males and 4 females) were tested after wearing a lumbar orthosis for 3 weeks. Because there was no statistical difference in proprioception between these 2 LBP groups (active repositioning: P=.134, passive repositioning: P=.416, motion perception threshold: P=.38), they were combined as 1 group for the comparison with the controls. The anthropometric data for LBP and control groups are presented in table 1. The LBP group consisted of subjects with pain persisting longer than 3 months and with no history of spinal surgery. Potential subjects were excluded if they had neurologic symptoms below the knee. Eleven subjects used pain medicine when needed, and 3 used pain medicine daily. Also, 2 subjects used muscle relaxants daily. The majority of subjects received some form of therapy in the past, including chiropractic, exercise, massage, and ultrasound. Before starting the experiment, all subjects read and signed an informed consent form that had been approved by the institutional review board.

Table 1. Anthropometric Data for Each Subject Group
Subject CharacteristicsControl (n=24)LBP (n=24)
Age (y)42.4±9.042.6±13.7
Height (m)1.71±0.081.69±0.1
Weight (kg)73.0±14.871.3±12.8
Visual analog scale (out of 10)NA4±2.6
Modified Oswestry disability index51 (out of 10)NA1.9±1.5
No. of y since the first episodeNA11.6±7.2
Days with back pain in the past 30d (no. of patients)
1–5NA1
6–10NA4
11–20NA8
20 or moreNA11

NOTE. Values are mean ± SD.

Abbreviation: NA, not applicable.

Protocol 

Subjects were tested in seated, supine, and side-lying positions, which corresponded to transverse, frontal, and sagittal planes of motion, respectively. The order of testing positions was randomized. The apparatus was modified from Cholewicki et al40 to provide rotations in all 3 anatomical planes while the upper body was immobilized (fig 1). The resolution of the apparatus was less than 0.01°, and the accuracy of the calibration curve was 0.35°. Subjects were positioned such that the axis of rotation passed through the L4/L5 spinal level. Subjects' upper bodies were fixed to the apparatus with straps, so that only their lower bodies rotated. To minimize tactile and visual cues, subjects were instructed to keep their arms crossed above their waist and to keep their eyes closed. The motor noise from the apparatus was masked by background music.

  • View full-size image.
  • Fig 1. 

    The apparatus for assessing proprioception in (A) axial rotation and (B) flexion and extension. For lateral bending, the same setup as flexion and extension was used, but the subjects were lying in a supine position.

Motion perception threshold, passive repositioning, and active repositioning were measured with protocols similar to those used in previous studies.36, 40, 41 For motion perception threshold, the stepper motor rotated the lower body at 0.1°/s away from the neutral position. The subjects were instructed to press a handheld button once they perceived a change in position and to report the direction of motion. The trials were recorded if the subject reported the direction correctly. For passive repositioning, the stepper motor moved the subjects' lower bodies 15° away from neutral at 2.2°/s. Once 15° was reached, the motor briefly paused and then started to return toward the neutral position at 1.0°/s. Subjects pressed the button when they perceived that they were back in the neutral position. Active repositioning was similar to passive repositioning, except that once the motor reached 15°, the clutch was disengaged and the subjects actively repositioned their lower bodies to the perceived neutral position. After reaching their perceived neutral position, subjects pressed the button and the angle was recorded. Subjects were given 2 practice trials in each plane of motion prior to data collection. In lateral and axial planes of motion, we preformed 4 trials in each direction. The data from left and right directions were combined. We increased the number of trials in the flexion and extension directions to 5 because they could not be combined, given that different anatomical structures would be involved.

Analysis 

The motion perception threshold was expressed as an absolute value in degrees. For each repositioning trial, an absolute error, referred to as “error” in this article, was computed as the absolute difference between the subjects' perceived neutral and the starting positions. We chose absolute error, instead of constant and variable error, as a more general measure of performance. For all tests, the 2 worst trials were rejected before averaging the values in flexion, extension, lateral bending, and axial rotation.36 Data were tested for their normality using an Anderson-Darling test. Box-Cox transformations were applied if data were not normally distributed. For the motion perception threshold test, 2-factor (group and planes), repeated-measures analysis of variance with the Tukey post hoc test was used (α=.05). For repositioning tasks, 3-factor (group, mode [ie, active or passive], and plane) analysis of variance was used to investigate differences in errors. All statistical analyses were performed with Minitab 13.1.a

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Results 

Demographic statistics indicated that there was no difference in age (P=.931), height (P=.782), or weight (P=.772) between LBP patients and healthy controls.

In the motion perception threshold test, the control group perceived smaller trunk displacement as compared to the LBP group (0.8±0.6° vs 1.3±0.9°, averaged across planes (F1,136=45.97, P<.001), which suggests that the healthy controls were more perceptive of trunk motion (fig 2). The plane of motion also had a significant effect on motion perception threshold (F3,136=8.04, P<.001). When averaged across groups, axial rotation had the greatest threshold (1.2±0.9°), followed by extension (1.0±0.7°) and flexion (1.0±0.9°), and then lateral bending (0.9±0.8°). A post hoc analysis revealed that motion perception threshold in axial rotation was significantly greater than the motion perception threshold in other planes of motion (P<.01). There was no interaction between the effects of group and plane of motion. During the motion perception threshold test, the LBP group reported the wrong direction in 5.4% of trials, whereas the control group reported the wrong direction in 6.3% of trials. These error rates were not significantly different between the groups according to the 2-proportion test (P=.569).

  • View full-size image.
  • Fig 2. 

    Motion perception threshold (MPT), and errors in active repositioning (AR) and passive repositioning (PR) tests, averaged across planes of motion. *Significant differences (P<.05).

Errors in the repositioning tests did not differ between the LBP group and the healthy control group (F1,318=0.65, P=.421) (fig 2). Generally, active repositioning was significantly more accurate than passive repositioning when averaged across groups and planes of motion (F1,318=4.64, P=.032) (table 2). There was a significant interaction between the effects of group and plane of motion (F3,318=3.0, P=.031). Post hoc analysis showed errors in extension of the control group were significantly smaller than in flexion (P=.001), axial rotation (P=.048), and lateral bending (P=.032). However, no such differences existed within the LBP group (see table 2).

Table 2. Average Motion Perception Threshold and Average of Absolute Error in Active Repositioning and Passive Repositioning
FlexionExtensionAxial RotationLateral Bending
ControlLBPControlLBPControlLBPControlLBPAverage
MPT(°)0.7±0.41.3±1.10.8±0.61.1±0.71.1±0.71.4±0.70.7±0.51.2±0.91.0±0.8
AR(°)2.3±1.32.1±1.11.6±1.52.3±2.01.7±0.91.8±0.91.8±0.92.0±0.81.9±1.2
PR(°)2.7±1.72.2±1.31.6±1.42.2±1.52.5±1.22.2±1.42.5±1.52.4±1.42.3±1.4

NOTE: Values are mean±SD. The LBP patients had significantly greater MPT averaged across planes of motion than healthy controls (P<.001). There was no significant difference between LBP and healthy control groups in the repositioning errors measured with AR or PR. However, AR had significantly smaller error than PR (P=.032).

Abbreviations: AR, active repositioning; MPT, motion perception threshold; PR, passive repositioning.

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Discussion 

Although many studies have investigated proprioception in LBP patients, it is still unclear whether people with LBP have impaired proprioception. Most studies tested patients with nonspecific LBP in limited planes of motion; hence, we modified the protocol from our previous studies36, 40, 41 and tested subjects in all 3 anatomical planes, comparing the LBP group to age-matched healthy controls. Furthermore, our study was designed to investigate position and movement aspects of proprioception, while eliminating inputs from visual and vestibular systems. We hypothesized that if proprioceptive impairments exist in the LBP group, they will more likely be revealed on the more sensitive motion perception threshold test than on the repositioning tests (which rely on memory recall). Our results showed that people with LBP have lower acuity for detecting changes in trunk position during motion perception threshold testing. Repositioning tasks, on the other hand, showed no difference between LBP and control groups. This finding supports our hypothesis that motion perception threshold is more sensitive than the repositioning tests for detecting proprioceptive impairments (passive repositioning and active repositioning). The values of proprioception measures in the current study were similar to those in previous studies that used motion perception threshold29, 41, 42 and repositioning tests40 under similar testing conditions.

Subjects in both groups had smaller errors in the active than in the passive repositioning test. This finding is consistent with results from previous studies in other body segments,38, 39, 43, 44 as well as the trunk.36 It has been suggested that sensory information provided by efferent input to the muscle spindles is greater when the muscle is active, which might improve joint positioning sense.8

It could be argued that the 2 passive tests (motion perception threshold and passive repositioning), which represent the proprioceptive sensitivity without significant muscle activation, should produce similar errors. However, the motion perception threshold was significantly smaller than the error in passive repositioning when averaged across groups and planes of motion (table 2). One reason for this difference might stem from memory recall, because the repositioning tests require the subjects to remember a target position. This requirement introduces memory bias to the repositioning tasks, which varies depending on the amount of time that elapses between the presentation of the target position and the movement execution.39 In contrast, subjects only need to detect a change in position during the motion perception threshold test, which could explain the higher within-session repeatability.36 Therefore, the motion perception threshold test appears to be more reliable than repositioning tests for assessing proprioceptive deficits.

Although the motion perception threshold test is more reliable than the repositioning tests, the 2 previous studies that used the motion perception threshold method provided conflicting results. Silfies et al found no difference in collegiate athletes between those with and those without history of LBP.36 However, Taimela found differences between patients with nonspecific LBP and healthy controls,29 which is similar to the result from this study. One possible explanation for different results is that the ability to detect small motion may have been affected more in the older LBP population in Taimela's study (average, 41y) than the in the population in the Silfies study (average, 19y). As part of natural aging process, the neural control of muscles degrades,45 and proprioception is also diminished.46, 47 Thus, the pathology associated with chronic LBP may accentuate the age-related neural changes, resulting in motion perception threshold differences seen only in the older LBP subjects29 and not the younger, athletic population in the Silfies et al study.36 It is also possible that the conflicting motion perception threshold results between these 2 studies are due to the level of proprioceptive training. Since training can improve proprioception,48, 49, 50 any proprioception deficit could be masked by high-performance training in collegiate athletes.

O'Sullivan et al argued that the inconsistencies in proprioception studies reflect the nonhomogeneity of subjects.28 For this study, most LBP subjects had nonspecific LBP (1 diagnosis of bulging disk and 1 spondylolysis). When the 2 subjects were excluded, the conclusions of this study did not change. Proprioception deficit may exist for subgroups of LBP, such as spinal stenosis,31 herniated disk,30 or lumbar segmental instability with a flexion pattern.28 However, our study indicates that even without such classifications, the impairment in proprioception can be detected if the motion perception threshold test is used.

Although this study showed impaired proprioception in patients with LBP, the current case-control experimental design cannot distinguish between cause and effect. Longitudinal prospective studies are needed to determine whether impaired proprioception could be a predisposing factor for LBP. The longitudinal studies can also determine the effects of various treatment modalities on trunk proprioception. Our study did not have sufficient power to correlate the magnitude of motion perception threshold with previous treatment received by the patients. Finally, we did not attempt to subclassify LBP patients based on any clinical measures. Such subclassification may reveal more information about the role of proprioception in LBP pathology and help determine prognosis for chronicity.

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Conclusions 

Although this is yet another study on proprioception in LBP, it contributes some methodological guidelines for future research. For example, with the more sensitive motion perception threshold test, it might be possible to detect proprioceptive differences between various subgroups of LBP patients and shed more light on the role of such impairments in LBP and its recurrence. Thus, additional studies are still needed until we can fully understand this phenomenon and be able to rationally incorporate such knowledge into the management of LBP.

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  • a Minitab Inc, 1829 Pine Hall Rd, State College, PA 16081.

 Supported by the National Institutes of Health (grant no. R01 AR051497).

 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

PII: S0003-9993(10)00309-6

doi:10.1016/j.apmr.2010.06.004

Archives of Physical Medicine and Rehabilitation
Volume 91, Issue 9 , Pages 1327-1331, September 2010

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