Thesis--Kansaneläkelaitos, 1989. / Added t.p. with thesis statement inserted.

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A dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfillment of the requirements for the degree of Master of Science in Physiotherapy. Johannesburg, 2014 / Cycling has grown in popularity as a sport and is rated as one of the top 15 most popular sports in South Africa with more than 420 000 participants. Cyclists spend long continuous hours on the bicycle in an awkward position, which leads to unique overuse injuries. Overuse injuries in cyclists have been estimated to be as high as 85% with lower back and pelvis pain (LBPP) among the most common. The lower back and pelvis is the foundation the cyclist use for powering and controlling the bicycle and optimal functioning thereof is essential for optimal comfort and performance in cycling. The prolonged forward flexed position of the cyclist on the bicycle is regarded as one of the main contributors to LBPP in cyclists. Cyclists with LBPP are known to assume a position of greater lumbar flexion compared to those without but the reason for this has not been extensively explored. The purpose of this study was therefore to not only establish the prevalence of LBPP in cyclists in South Africa, but also identify factors associated with it in cyclists. The factors were considered in three broad categories: (1) training methods used, (2) intrinsic functioning of the cyclist and (3) bicycle set-up. Intrinsic and bicycle set-up factors included were those proposed to influence the forward-backward and side-to-side position of the cyclist on the bicycle and thereby lead to the development of LBPP in cyclists. The study had a cross-sectional descriptive design and comprised of two parts: a questionnaire (survey) investigating the prevalence of LBPP in cyclists together with the training methods used, and a physical assessment of the factors proposed to be associated with LBPP in cyclists. All cyclists belonging to cycling clubs registered with Cycling South Africa were invited to complete the online survey. From there, cyclists could indicate willingness to undergo a physical assessment which was done in the greater Gauteng area. The physical assessment included the following measurements: the lumbar curvature on the bicycle in all three handlebar positions, strength of gluteus maximus and gluteus medius, extensibility of the hamstring muscle group, control of lumbar movement in the direction of flexion, neurodynamics, active straight leg raise for load transfer, one leg stance test for lateral shift of the pelvis, leg-length discrepancy and bicycle set-up (saddle height, set-back and angle, handlebar height, forward reach, cleat position). The study revealed a lifetime prevalence of 65% for LBPP among cyclists in South Africa. Of the factors assessed, only the lumbar curvature in the brake lever position i.e. flexion of the lumbar spine (p=0.03) and the weakness of gluteus medius (Gmed) (p=0.05) were significantly related to LBPP in cyclists. This study was the first to assess the relationship between so many different factors and LBPP in cyclists, and the largest of its kind in cycling. Understanding the relationship between these factors and LBPP in cyclists can guide the development of preventative strategies and interventions with the aim of reducing the occurrence and recurrence of LBPP in cyclists and limiting the impact thereof.

Introduction Low back pain can be influenced by demographic, lifestyle and co-morbid factors. No studies have been done on the relationship between these factors and low back pain in hospital employees in South Africa. The aim of this study was to determine which of these factors was present and how they influenced low back pain in staff employed at a district hospital in South Africa. Methods The study used a self-administered questionnaire on staff employed at the hospital. Results Results indicated that the point prevalence for low back pain was 47%. Most of the employees were female nurses aged between 26 and 40 years with BMI values higher than normal. The majority of the employees participated in exercises although this was mainly for 1 to 2 times a week. Among the demographic factors, only female gender was associated with increased risk of low back pain (OR 1,67 CI 1,04 ; 2,69) while for the lifestyle factors, participation in group exercises was a protective factor against low back pain (OR 1,66 CI 1,02 ; 2,70). Perceived stress all the time increased the risk of low back pain (OR 3,47 CI 1,46 ; 8,23). None of the isolated co-morbid diseases were associated with the presence of low back pain. Conclusion The prevalence of low back pain among Tshwane district hospital employees is high. Female gender and a high level of perceived stress increase the risk of low back pain while participation in group exercise reduces the risk of low back pain.

MSc, Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand / The Association between Trunk Muscle Endurance and Lumbar-Pelvic Instability in Adolescent Low Back Pain Françoise Lewis Supervisors: Wendy-Anne Wood, Benita Naude. Low back pain (LBP) is a common cause of discomfort in modern society, and the prevalence of LBP in the adolescent population is high and has a predictive value for the occurrence of LBP as an adult. The aim of the study was to investigate the association between adolescent LBP and trunk muscle endurance and lumbar-pelvic instability, as well as the association between trunk muscle endurance and lumbar-pelvic instability. Sports and physical activity participation, sedentary activity participation and a family history were also investigated as they have been identified in previous studies as potential risk factors. The study was a cross sectional study of 80 adolescents in grade 8 to grade 11, aged 12 to 17 year , at three high schools in Gauteng, who agreed to participate in the study. Data was collected by means of a validated questionnaire and a physical examination. The level of significance for as sociated factors was set at 0.05. The results revealed a lifetime prevalence of 82.50%, one year prevalence of 78.80% and point prevalence of 23.80%. Adolescents with LBP have decreased endurance of the trunk extensor muscles but increased endurance of the trunk flexor muscles, which is statistically significant (p=0.044) . Lumbar-pelvic instability is not associated with adolescent LBP. Extensor trunk muscle endurance and poor lumbar pelvic stability show an association (p=0.031), with those adolescents with decreased trunk extensor muscle endurance presenting with poor lumbar-pelvic stability. A family history of LBP is significant for point prevalence of LBP (p=0.012), and one-year prevalence of LBP is marginally significant (p=0.086). Low activity level particpation was reported by a large percentage of all subjects. Sedentary activity participation is moderate in the LBP group, but the results are not statistically significant . There is a need for preventative srategies to decrease the prevalence of adolescent LBP. Increased awareness of LBP and potential risk factors needs to be addressed.

Motivation Occupational driving has often been associated with a high prevalence of low-back pain (LBP). Truck drivers in the petrochemical industry in South Africa are vulnerable to occupational related LBP because of the very nature of their job, and this vulnerability has to date not been quantified. The individual and job factors that contribute to cause this pain are diverse and might include prolonged sitting, exposure to whole-body vibration, heavy physical work, smoking and other psychosocial factors. Studies on the prevalence and knowledge of the risk factors associated with occupational related LBP are important since they allow not only for the determination of the impact of the condition on society or on a given social stratum, but can also help to organize health services and channel investments necessary for the prevention and control of occupational related LBP. Aim The aim of this study was to determine the prevalence of occupational related LBP in a defined cohort of truck drivers and to ascertain if certain risk factors i.e. demographic factors of the truck drivers, manual material handling (heavy physical work), static work posture and perceived levels of whole-body vibration are associated with truck driving and LBP. Methods The study design chosen was descriptive, cross-sectional and quantitative in nature. For the study, the widely established “Standardized Nordic Questionnaire” (SNQ) was used to collect data. The questionnaire was divided into three sections, viz. biographical, low-back pain, and risk factors for ease of completion by the participants of this study. A total of 450 drivers participated in the study by completing the questionnaire. SPSS version 15.0 (SPSS Inc., Chicago, Illinois, USA) was used to analyze the data. Descriptive and inferential statistics was used in the analysis of the data. Results Of the 450 drivers, 385 (86%) experience LBP and 65 (14%) reported to have not experienced any form of LBP. On the scale of 0 to 10, 68 drivers (15%) indicated that they had pain as bad as it could be, whereas 32 drivers (7%) indicated that they suffered no back pain at all. When the severity of the pain was categorised, as low, medium and high, 40.5 % of the LBP respondents indicated that they had a high severity of LBP. Smoking, static work posture and total years of driving were all found to be significantly associated with LBP. Whole-body vibration, body mass index (BMI) and heavy physical work were found to have no association with LBP which was not expected. Conclusion The prevalence of occupational related low-back pain in petrochemical truck drivers was 89%. Smoking, static work posture and total years of driving were the risk factors associated with LBP amongst the truck drivers.

Thesis (Ph. D.)--Virginia Commonwealth University, 2006. / Prepared for: Dept. of Health Administration. Bibliography: leaves 176-192. Also available online.

Abstract Introduction. The biopsychosocial model has developed over the last forty years since Melzac and Wall first stated the need to broaden the biomedical view of pain mechanisms. The biopsychosocial concept is now central in contemporary understanding of human health and functioning in general, and pain in particular. An extensive biopsychosocial literature on low back pain has emerged since the paradigm shift of nearly thirty years ago, and has been reflected in evidence-based clinical practice guidelines on musculoskeletal pain. The estimation of prognosis from an episode of low back pain is particularly important to clinicians, patients, employers and third party payers. The instruments currently available however, quantify prognostic factors from a biomedical perspective, rather than the contemporary biopsychosocial model. The successful development of the biopsychosocial instrument, reported in this thesis, fills this gap in measurement, and affirms the hypothesis advanced that it is feasible to develop a valid and reliable multidimensional index to estimate prognosis from a range of biopsychosocial variables, in low back pain. The thesis describes; • A review of pain mediation/modulation • A review of the literature on the biopsychosocial model to identify a range of variables for investigation • Consideration of different outcome measures as the gold standard criterion measure • The development of the BPIP, a novel biopsychosocial instrument designed for eventual clinical use, as a means of considering non specific low back pain from a biopsychosocial perspective, and informing prognosis in patients who do not have diagnosable levels of psychopathology Methods. The Biopsychosocial Index of Prognosis (BPIP) was developed from a content map derived from the International Classification of Functioning, Health and Disease (ICF) for use in non specific low back pain of variable duration. A prototype BPIP instrument was drafted, and a peer review process resulted in item reduction. The prototype BPIP instrument was then subjected to a twenty four hour test-retest assessment of stability, prior to assessment of the prototype BPIP’s validity and internal consistency. Questionnaire packs containing the prototype BPIP instrument, a range of other measurement instruments, an informed consent form and an instruction sheet were then issued. The data were captured at baseline, six weeks, and again at twelve weeks. Recruitment of respondents was originally intended to capture a homogeneous cohort drawn from general (medical) practice. Recruitment difficulties however resulted in two distinct cohorts, a larger Australian cohort (n = 91) and a smaller New Zealand cohort (n = 27). The larger Australian group was utilised as an elucidation cohort, and the smaller New Zealand cohort was treated as a small prospective validation of the BPIP. Item reduction was undertaken and resulted in an ordinal scale for correlation with the Roland and Morris Disability Index, the criterion measure. The resulting twenty four item BPIP scale was tested for internal consistency in both the Australian and New Zealand cohorts. The baseline data from the Australian elucidation cohort were then assessed for concurrent, predictive and construct validity against the twelve week data from The Roland and Morris Disability Index (RDQ), the selected criterion measure. The New Zealand cohort was treated as a small prospective validation of the BPIP scale, with the baseline data from the BPIP correlated with the change score from the baseline to twelve weeks, of the RDQ. Analysis was undertaken using the SPSS statistical package. Results. Correlation analysis of the baseline BPIP Australian data with the twelve week RDQ Australian data resulted in reducing the prototype scale to questions which correlated at or above 0.3, a total of twenty four questions were retained. Reliability coefficients for internal consistency of the twenty four item BPIP scale were: The Australian cohort, Cronbach’s Alpha = 0.8736. The New Zealand cohort, Cronbach’s Alpha = 0.8628. A further review of the correlation analysis of the baseline BPIP Australian data with twelve week RDQ Australian data for items that correlated at or above 0.4 resulted in further item reduction of the BPIP to twelve questions. Following this further item reduction, reliability coefficients for internal consistency were: The Australian cohort, Cronbach’s Alpha = 0.875. The New Zealand cohort, Cronbach’s Alpha = 0.776. Regression analysis of the Australian cohort based on the twelve item scale demonstrated that 61.7% of the variance in the RDQ score at twelve weeks was accounted for by the BPIP scale, with p = 0.0005. Regression analysis of the change score of the RDQ with the twelve item BPIP in the New Zealand cohort demonstrated that 78.2% of the variance in RDQ scores was accounted for by the BPIP scale, with p = 0.006. Forty five point five percent of the Australian cohort improved by more than 30%, (the proposed minimal clinically important difference of the RDQ), whilst 76.9% of the New Zealand cohort improved more than thirty percent. In a post hoc analysis of the Orebro data, the longer 25 item questionnaire accounted for 97.8% of the variance in the New Zealand cohort. Conclusion. The initial hypothesis that it would be feasible to develop a valid and reliable multidimensional instrument from a range of biopsychosocial variables into a valid instrument for estimating the prognosis of an episode of low back pain is supported by the results. The utility of a biopsychosocial instrument for routine clinical use lies in the potential to predict prognosis. As low back pain is typically a recurrent problem, information on both prognosis for recovery from episodes, and the likelihood of recurrences would be helpful to both clinician and patient. For the patient, a well communicated prognosis helps assure the patient about their future, reduces uncertainty about their pain, and establishes treatment goals within the domain of informed consent. From the clinician’s perspective, a prognostic approach shifts the focus from the pain history to future outcomes and provides a context for considering how risks of future pain and dysfunction may be reduced. The BPIP scale is a biopsychosocial, prognostic instrument, which accounts for a high degree of the variance in the RDQ scores in both cohorts. Pain amelioration and functional improvement are the two key aspects of prognosis which the BPIP has been demonstrated to be both valid and reliable in predicting at the clinically important three month time point from baseline assessment. The BPIP has been demonstrated in these cohorts, to provide a reliable estimate of prognosis from a biopsychosocial perspective. The reliability of the shortened BPIP scale remained acceptable, and allowed for the scale to be contained on a single A4 page, potentially increasing the clinical utility of the instrument. When BPIP score fails to change over time, psychosocial screening and intervention may be indicated. Future work will include further validation in other subgroups and clinical environments, identification of cut points for BPIP scores, and the performance of comparative studies of the relative value of different purported prognostic indices. The BPIP is the first instrument developed to specifically to estimate prognosis from an episode of low back pain, in primary care, within the contemporary biopsychosocial model.

Standing at a workbench is required for manual work including sorting and assembly. When work heights and reach distances are not matched to stature or arm length, the trunk assumes a partially bent position, which increases the postural effort required to stand or to reach to far distances. As a result, the biomechanical load on the lumbar spine is raised, which contributes to a higher risk for back pain. In ergonomics, assistive devices are being developed to counter this effect. A new leaning device was tested in the laboratory with forward-bent standing and reaching where the trunk was bent forward and twisted to reach to a far target 45° from the center. This device supported the trunk at the upper chest. With leaning, back muscle activity decreased by ~ 60% with forward-bent standing and ~ 23-30% with the off-center reach, depending on reach height. Because leaning changed how standing remained balanced, ~12° less bending was required to reach the target. Therefore, upper-trunk support may be helpful for benchworkers when ergonomic design is not possible; some product development and testing is still needed to provide the right amount of support at the right time and to ensure there is no rib joint irritation. An interesting outcome from these previous studies was related to workers’ posture when they leaned against a workbench that was adjusted for heavier work (hip height). Low back muscle activity was unchanged with forward-bent standing, but decreased by ~ 23-30% with the off-center reach. This reduction was accompanied by greater twist at the mid back as a way of compensating for a loss of hip rotation. Three different heights for bench leaning were compared in a third study: elbow height, hip height and below hip height. The results showed that leaning at elbow height lowered the work demand by ~16-24% for far reach, partially due to changed motions consistent with greater mid back movement and coincided with ~ 8% increase in work demands at the mid-back and greater scapular recruitment. Therefore, more research is needed to establish work height guidelines for use when leaning against a workbench. / Thesis (Ph.D, Kinesiology & Health Studies) -- Queen's University, 2013-01-29 14:32:19.696