Relationship Between Mechanical Factors and Incidence of Low Back Pain

Mohammad Reza Nourbakhsh, PT, PhD 1 Amir Massoud Arab, PT, MSc2

RESEARCH REPORT

Study Design: A multifactorial cross-sectional nonexperimental design. Objectives: To collectively investigate the association among 17 mechanical factors and occurrence of low back pain (LBP). Background: Several physical characteristics, based on assumptions, clinical findings, and scientific experiments, have been associated with the development of LBP. Controversy exists regarding the degree of association between some of these physical characteristics and LBP. Information regarding the degree of association of each factor to LBP is needed for effective prevention and appropriate treatment strategies. Methods and Measures: A total of 600 subjects participated in this study. Subjects were categorized into 4 groups: asymptomatic men (n = 150, age [mean SD] = 43 15 years), asymptomatic women (n = 150, age [mean SD] = 43 13 years), men with LBP (n = 150, age [mean SD] = 43 14 years), and women with LBP (n = 150, age [mean SD] = 43 13 years). Seventeen physical characteristics were measured in each group and the relative association of each characteristic with LBP was assessed. Results: Among all the factors tested, endurance of the back extensor muscles had the highest association with LBP. Other factors such as the length of the back extensor muscles, and the strength of the hip flexor, hip adductor, and abdominal muscles also had a significant association with LBP. Conclusion: It appears that muscle endurance and weakness are associated with LBP and that structural factors such as the size of the lumbar lordosis, pelvic tilt, leg length discrepancy, and the length of abdominal, hamstring, and iliopsoas muscles are not associated with the occurrence of LBP. J Orthop Sports Phys Ther 2002;32:447460.

Lumbar Lordosis
Two major theories have long speculated that changes in the size of the lumbar lordosis are the main cause of LBP.82,123 Williams123 attributed LBP to the increased lumbar lordosis resulting from abdominal muscle weakness due to prolonged sitting posture. In contrast, Mckenzie82 attributed LBP to decreased lumbar lordosis and posterior displacement of the nucleus pulposus of the intervertebral disc in the lumbar spine. To validate these assumptions, the effects of lumbar flexion and extension exercises on LBP have been studied. Flexion exercises, which are assumed to decrease lumbar lordosis, have been found to have the same effect on reducing LBP as extension exercises, which are expected to increase the lumbar curve.16,29,32,40,78,127 This issue has been further investigated, and no relationship has been found between the size of lumbar lordosis and development of LBP.27,30,37,41,87,96,124 These findings have led to questions regarding the rationale behind these two major theories and the subsequent treatment programs.

Key Words: back extensor endurance, low back pain, lumbar lordosis, muscle length, muscle strength

ow back pain (LBP) is one of the most frequent healthrelated complaints in western societies.110 Previous studies have indicated that 70% to 80% of the western population have had at least 1 episode of LBP in their lifetime.110,120 Despite its detrimental association with social and workrelated activities, the exact cause of mechanical LBP has not yet been determined. Several factors, based on assumptions, clinical findings, and scientific experiments, have been associated with the development of LBP. However, with the use of different designs and testing procedures, controversial results have been reported in the literature.
1

Pelvic Tilt
Assistant professor, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. 2 Physical therapist, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. This study was partially supported by the University of Social Welfare and Rehabilitation Sciences and approved by the Human Subject Committee of the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. Send correspondence to Mohammad Reza Nourbakhsh, Dr. Chamran Highway, 5th (Kaj) Street Number 30, Tehran 14417, Iran. E-mail: mrezanourbakhsh@yahoo.com

Based on the anatomic relationship between the pelvis and the lumbar spine, it has been speculated that changes in the pelvic inclination affect the size of the
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lumbar lordosis and cause LBP.1,18,26,65,67 Both of these assumptions have been challenged. Some studies demonstrated that there was no correlation between the angle of pelvic inclination and the size of the lumbar lordosis.6,116,121,124 Although Roncarati and McMullen99 found that there was an increased anterior pelvic tilt in patients with LBP, others have not found a significant difference in the angle of pelvic inclination among asymptomatic subjects and subjects with LBP.21,27,30

Iliopsoas Muscle Length

Some studies have shown decreased iliopsoas muscle length3,84 and strength73 in patients with LBP. Because the iliopsoas muscle attaches to the pelvis and lumbar spine, some have assumed that tightness of this muscle causes increased lumbar lordosis and that weakness of this muscle causes decreased lumbar lordosis, which, in turn, can result in LBP.18,67,105 Recent studies have found no association between the length of the iliopsoas muscle and the size of the lumbar lordosis,116,124 between the size of the lumbar curve and LBP,27,30,37,41,87,96,124 or between tight iliopsoas muscle and LBP.45

Abdominal Muscle Length and Strength

Based on the anatomic position and function of the abdominal muscles, it has been speculated that abdominal muscle weakness produces an anterior pelvic tilt and lumbar hyperlordosis, resulting in LBP.1,18,26,61,65,67 In addition, several studies have found decreased abdominal muscle strength in patients with LBP.3,46,73,83,88 In contrast to these findings, some investigators have found that there is no association between the angle of pelvic inclination, the size of the lumbar lordosis, and abdominal muscle strength.75,121,124 Moreover, other studies have shown no significant difference in abdominal muscle strength between asymptomatic individuals and those with LBP.5,74,106,113 Finally, some reports have demonstrated that no association exists between the length of the abdominal muscles and the size of the lumbar lordosis.116,124

Hamstrings Muscle Length

Hamstrings tightness is one of the most common findings in patients with LBP.1,18,52,54,61,65,84,105 It is thought that, due to the attachments of hamstrings to the ischial tuberosity, hamstrings tightness generates posterior pelvic tilt and decreases lumbar lordosis, which can result in LBP.1,18,65,84,105 Hellsing,45 however, examined 600 young men and concluded that no association existed between hamstrings tightness and LBP. Van Wingerden et al118 suggested that hamstrings tightness in patients with LBP is a compensatory mechanism secondary to pelvic instability.

Leg Length Discrepancy

Several studies have shown the presence of leg length discrepancy in patients with LBP.43,99,111 Leg length inequality is thought to cause LBP by generating a lateral pelvic inclination and lumbar scoliosis.33,81 Schaffer105 believes that leg length discrepancy causes anterior innominate rotation on the side of the shorter leg and posterior innominate rotation on the side of the longer leg. Innominate rotation is thought to cause sacral tilt, affecting the lumbosacral articulation. Hoikka et al,49 however, support neither of the above hypotheses. They showed that leg length discrepancy had a moderate correlation with sacral tilt, and a poor correlation with lumbar scoliosis. Others have also questioned the association between leg length inequality and LBP.21,39,107,126

Back Extensor Muscle Endurance

Back extensor muscles are considered postural muscles that aid in maintaining upright standing posture and controlling lumbar forward bending.18 Several studies have reported a significant decrease in back extensor muscle endurance in patients with LBP.3,8,18,19,51,58,101 It is thought that decreased back muscle endurance causes muscular fatigue and overloads soft tissue and passive structures of the lumbar spine, resulting in LBP.79,122

Back Extensor Muscle Flexibility

According to Williams theory of LBP, prolonged sitting causes back extensor muscle tightness, which, in turn, overstresses the lumbar spine, resulting in LBP.65,123 Janda54 and Jull and Janda61 classify back extensors as postural muscles, which have a tendency to shorten with overstress and back pain. Other investigators have also shown decreased flexibility and back muscle tightness in patients with LBP.14,52,70,117 Some studies, however, have found no difference in the flexibility of back extensor muscles in athletes with and without LBP,3,119 which may be due to enhanced general flexibility in the athletic population.
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Iliotibial Band Tightness

Stretching of the iliotibial band is frequently recommended in treatment programs for patients with LBP.71 Because the iliotibial band attaches to the ilium, tightness of this muscle is thought to cause anterior innominate rotation and lateral pelvic tilt.61,105 We found no study that has directly evaluated the effect of tightness of the iliotibial band on LBP.

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Foot Pronation
The relationship between subtalar joint pronation and LBP has been previously reported in some case studies.12,23 It is suggested that excessive foot pronation may produce lower-extremity medial rotation,11,90 functional leg length disparity,11,25 and pelvic obliquity.11,100 Increased pelvic obliquity, as suggested by Botte,11 creates lateral deviation and a functional scoliosis of the lumbar spine. Unilateral leg shortening and excessive medial rotation of the limb is thought to produce anterior pelvic tilt11,104 and increased lumbar lordosis.11 These structural imbalances caused by unilateral foot pronation presumably result in LBP in some patients.11,12,23 Further research is indicated to determine the significance of foot pronation in the development of LBP.

ously, can lead to LBP. However, the significance of calf muscle tightness in the development of LBP has not been determined.

RESEARCH REPORT

Objectives
As noted above, controversy exists regarding the association between various physical characteristics and the occurrence of LBP. In addition, the association between several other physical characteristics and LBP has not yet been scientifically examined. Most previous studies have considered only a few physical characteristics and have been performed on a relatively small population. Furthermore, the factors that have the greatest association with the incidence of LBP have not yet been identified. This study collectively investigates the association between several characteristics and LBP in a large population and identifies the relative association of each factor with LBP.

Hip Abductor and Adductor Muscle Flexibility and Strength

Hip abductor and adductor muscles play a significant role in pelvic lateral stability.71 Any imbalance in the function of these muscles due to muscle shortening or weakness may cause pelvic obliquity and functional lumbar lateral bending.65 Vertebral rotation coupled with vertebral lateral bending may overstress lumbar soft tissue and facet joints.105 Furthermore, considering the role of these muscles in sacroiliac joint stability,71 any disturbance in their function can lead to sacroiliac joint instability and LBP. However, the effect of weakness or shortening of these muscles on LBP has not been directly assessed.

METHODS Subjects
A total of 600 subjects between the ages of 20 and 65 were randomly recruited from 5 hospitals in Tehran, Iran. Subjects were categorized into 4 groups: asymptomatic men (n = 150, age [mean SD] = 43 15 years), asymptomatic women (n = 150, age [mean SD] = 43 13 years), men with LBP (n = 150, age [mean SD] = 43 14 years), and women with LBP (n = 150, age [mean SD] = 43 13 years). To account for the effect of age on the considered variables, the subjects in each group were further divided into 3 age ranges (ages 2035, 3650, and 5165 years). Subjects were recruited so that an equal number of individuals (n = 50) in each age range were allocated to each group. The mean age, height, and mass of the subjects in each group are shown in Table 1.

Triceps Surae Muscle Flexibility

Calf muscles are classified as postural muscles, which, according to Jull and Janda,61 have a tendency to shorten in reaction to physical stress or injury. Triceps surae muscle tightness can cause foot pronation31 and leg length discrepancy (flexed knee). Both of these conditions, as discussed previ-

TABLE 1. Age (mean SD), height, and mass of asymptomatic subjects and those with low back pain. Men Variables Age 2035 (y)* Age 3650 (y)* Age 5165 (y)* Height (cm) Mass (kg) * n = 50 per group. n = 150 per group. Asymptomatic 26 4 42 4 61 5 170 6 72 11 Low Back Pain 27 5 41 4 60 5 172 7 74 11 Asymptomatic 28 4 43 4 58 5 166 7 66 11 Women Low Back Pain 28 43 58 160 68 4 5 4 6 10

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Selection Criteria
Subjects (symptomatic and asymptomatic) were included if they had no history of spinal surgery, no spinal or pelvic fracture, no history of hospitalization for severe trauma or injuries from a car accident, no history of osteoarthritis or fracture of the lower extremities, and no history of any systemic disease, such as arthritis or tuberculosis. Asymptomatic subjects were selected among those who either accompanied a patient or were referred to the hospital for nonmusculoskeletal problems. These subjects were evaluated and found to have no complaint of any pain or dysfunction in their lower extremities, low back, thoracic and neck areas. Patients were included if they had a history of LBP for more than 6 weeks before the study or had on-and-off back pain and had experienced at least 3 episodes of LBP, each lasting more than 1 week during the year before the study. None of the subjects with or without LBP had referred leg pain. Individuals with leg pain were excluded from the study. Sixty-eight percent (n = 204) of the patients had LBP for more than 6 months and complained of pain and stiffness in the lower back at the time of the study. Before participating in the study, all subjects signed an informed consent form approved by the University of Social Welfare and Rehabilitation Sciences Human Subjects Committee.

0
A

FIGURE 1. Inclinometer used to measure pelvic tilt. (A, plumb line indicates 0 when the inclinometer is parallel to the ground; B, plumb line shows the tilting angle of the inclinometer.)

Reliability Assessment
Intratester reliability of the measurements was assessed using 20 men and 20 women asymptomatic volunteers. Except for the measurements of endurance of the back extensor muscles, foot arch height, and the strength of the abdominal, hip flexor, hip extensor, hip abductor and hip adductor muscles, the rest of the variables were tested by 2 examiners to establish intertester reliability. The first examiner completed the tests on a subject and after 15 minutes repeated the tests in a random order on the same subject. The second examiner then tested the subject following the same procedure.

Procedures
Several variables were measured in this study. A description of the procedure and instruments used to measure each variable is as follows. Size of Lumbar Lordosis A standard flexible ruler was used to measure the size of the lumbar lordosis in the standing position based on the method explained by Youdas et al.124,125 Angle of Pelvic Tilt An inclinometer manufactured in our laboratory was used to measure the angle of pelvic tilt (Figure 1). This instrument was composed of a 360 scaled dial mounted on a horizontal bar. Two adjustable moving pointers were placed at each end of the bar. A plumb line was suspended from
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the center of the dial. When the horizontal bar was held parallel to the ground, the position of the plumb line on the dial would indicate the 0 angle (Figure 1A). When the inclinometer was tilted, the position of the plumb line would show the angle of tilt (Figure 1B). The inclinometer was calibrated and had 98% measurement accuracy. To measure the angle of pelvic tilt in standing posture, one of the pointers was placed over the anterior superior iliac spine (ASIS) and the other was placed over the posterior superior iliac spine (PSIS). The angle between the two landmarks, as indicated on the scaled dial, was considered to be the angle of pelvic tilt.13,75,116,121,124 Length of Abdominal Muscles Previous studies have used the prone press-up maneuver to estimate the length of the abdominal muscles.14,114,116,124 With this procedure, it is assumed that the abdominal muscles are lengthened in a direction opposite to their action.124 We hypothesized that limited lumbar extension due to bony contact between the spinous processes,64 in addition to pain and stiffness, might limit full abdominal muscle lengthening. In this study, the length of the abdominal muscles was estimated by measuring the distance between the xiphoid and the symphysis pubis in erect standing posture. The value obtained was normalized by dividing it by the length of the subjects trunk, measured as the distance from the top of the head to the level of the second sacral vertebra (S2). It was assumed

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that the pressure from the internal organs in relaxed standing position would stretch the abdominal muscles to their resting length. Length of Low Back Extensor Muscles The degree of maximum lumbar flexion was used as an indicator of the length of the back extensor muscles.15,114,124,125 A flexible ruler was used and the procedure described by Youdas et al125 to measure the subjects maximum lumbar flexion in the sitting position was followed. The quantitative method described by others15,125 was used to obtain the amount of maximum lumbar flexion in degrees. Length of Hip Flexor Muscles The length of the hip flexor muscles was assessed indirectly based on the Thomas test described by Kendall65 and Magee.77 The detailed instructions provided by Youdas et al124 to measure the angle between the longitudinal axes of the trunk and the thigh of subjects on the ipsilateral side to that of the assessed muscles were followed. Angles that measured less than 180 indicated the level of tightness in the hip flexor muscles. The average of the measurements obtained from the right and left side was recorded as the length of the hip flexor muscles. Length of Hamstring Muscles In this study, the active knee extension test described by Gajdosik et al36 was used to measure the length of the hamstring muscles. Others have used the straight leg-raising (SLR) test to assess the length of these muscles.34,35,50,84,116 Bohannon,10 however, argues that, due to pelvic rotation with the SLR test, it may not be an accurate means to measure the length of the hamstring muscles. The average of the measurements obtained from the right and left side was recorded as the length of the hamstring muscles. Length of Hip Adductor Muscles Measurement of passive hip abduction was used to estimate the length of the hip adductor muscles. The subject was instructed to lie supine on a treatment table with the hips and knees straight and arms folded across the chest. The center of a goniometer was placed over the symphysis pubis while one examiner, palpating the ASIS, monitored pelvic motion, and the other examiner slowly moved the subjects leg into hip abduction just to the point before the pelvis started to move. The angle between the body midline and the longitudinal axis of the femur of the tested leg, measured in degrees, represented the indirect length of the hip adductor muscles. The subjects leg was brought back to the starting position, and the procedure was repeated for the other leg. The average of the measurements obtained from the right and left side was recorded as the length of the hip adductor muscles. Endurance of Erector Spinae Muscles Erector spinae endurance was assessed with the subject lying prone on a treatment table with the hands laying beside his or her trunk. The subject was instructed to lift the

upper trunk exactly 30 from the table and to hold this position for as long as possible. The detailed procedure for this test is described by Ashmen et al.3 The length of time, measured in seconds by a stopwatch, that subjects could hold this designated angle was considered to be the measure of erector spinae endurance (Figure 2). At the end of the test procedure, the subjects were asked if pain was a limiting factor to maintain the position longer. The subjects who had pain during the testing procedure were excluded from the study. Length of the Gastrocnemius Muscles The passive dorsiflexion test, previously described by Johnson and Gross,57 was used to assess the flexibility of the gastrocnemius muscles. The average of the measurements obtained from the right and left side was recorded as the length of the gastrocnemius muscles. Length of the Iliotibial Band The Ober test was performed to assess tightness in the iliotibial band.31,77 This test was performed in the side lying position. The subjects lower leg was flexed at the hip and knee joints. The examiner, standing behind the subject, stabilized the pelvis with one hand, and with the other hand passively abducted and extended the hip with the knee flexed. Maintaining extension and neutral position of the subjects hip, the examiner allowed the testing leg to drop toward the table. If the subjects leg remained abducted, the subject was considered to have iliotibial band tightness.77 No quantitative measures were taken, and, based on test results, subjects were categorized as with or without iliotibial band tightness. Leg Length Discrepancy The length of each lower extremity was measured with the subject lying supine on a treatment table. The reference leg length was measured from the ASIS to the distal medial malleolus with a measuring tape.21,55,57,62,69 Leg length

RESEARCH REPORT

FIGURE 2. Procedure for measuring the back extensor muscle endurance. The subject is lying prone on a treatment table with the hands lying beside his/her trunk. The subject was instructed to lift the upper trunk exactly 30 from the table and hold this position for as long as possible.
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differences greater than 10 mm were considered abnormal,38,99 and subjects were categorized as with or without leg length disparity. Foot Arch The configuration of the longitudinal arch of the foot was used to determine foot pronation in subjects.22 The subject was instructed to stand on water-soaked foam to wet the soles of the feet. An impression was then made by asking the subject to step on a block of wood with weight evenly distributed on both feet. The index proposed by Staheli et al,109 the ratio of the width of the foot in the arch area to the width of the heel, was used to determine the level of foot pronation in subjects. The average of the measurements obtained from the right and left side was recorded as the index of foot arch. Testing Muscle Strength To measure muscle strength in an objective and quantitative fashion, a pressure meter similar to the one described by Helewa et al43 was used (Figure 3A). The reliability and validity of using pressure meters for measuring muscle strength has previously been established.42 The unit used in this study was calibrated and had 99% linearity. Muscle strength was assessed for the hip flexors, hip extensors, hip abductors, hip adductors, and abdominal muscles. Test methods were similar to those described for manual muscle testing of the above muscles,65 except that the inflated bag of the pressure meter was placed between the examiners hand and the specified contact point on the subjects limbs or trunk (Figure 3B). Helewa et al44 provide detailed instructions for using pressure meters to assess abdominal and hip flexor muscle strength. At the end of the test procedure, the subjects were asked if their ability to perform the test was limited due to pain or lack of strength. If pain was a limiting factor for a subject to produce maximum muscle force, that subject was excluded from the study. The average of the measurements obtained from the right and left side was recorded as the strength of the hip flexor, hip extensor, hip abductor and hip adductor muscles.

3A

3B

FIGURE 3. The pressure meter (A) and the method of use (B) to assess the strength of the hip flexor muscles.

Data Analysis
We used an intraclass correlation coefficient (ICC) and 2-way mixed-effect model108 to assess intertester and intratester reliability of the measurements. A Pearson correlation coefficient was used to assess correlation between the variables of the study. We tested quantitative data by using 2 2 ANOVA, accounting for sex, health status (symptomatic versus asymptomatic), and interaction of health status and sex effects. We used pooled data where there was no significant health-status-by-sex interaction effect, but analyzed the data separately for men and women for the variables which had a significant health-status-bysex interaction. Categorical data (iliotibial band length, and leg length discrepancy) were assessed by
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chi-square analysis. To determine the degree of association between LBP and physical characteristics, only those characteristics that we found to be significantly different between subjects with and without LBP were selected. Backward logistic regression analysis was used to determine the degree of association between each selected variable and LBP. Logistic regression analysis is a statistical procedure used to assess the degree of association between a dichotomous dependent variable and the independent variables.68 This procedure can also be used to determine the effect of independent variables on the probability (likelihood) of occurrence of the dependent variable.68

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RESULTS
Table 2 presents the ICC for each of the 15 measurements taken in the pilot study. Except for the indirect measurement of the length of the hip flexor (ICC = 0.72 and 0.75), abdominal (ICC = 0.79) and triceps surae (ICC = 0.77 and 0.78) muscles, all other ICC values were greater than 0.80. The result of the ANOVA revealed that sex by health status was significant for back extensor muscle length, back extensor muscle endurance, and abdominal muscle strength at 0.05 (Table 3).
TABLE 2. Intraclass correlation coefficient (ICC) values for intratester and intertester reliability for the 15 measurements performed in the study (n = 40 subjects). ICC Measurements Lumbar lordosis Back extensor length Pelvic tilt Abdominal muscle length Iliopsoas length Hamstrings length Hip adductor length Triceps surae length Back extensor endurance Abdominal muscle strength Hip flexor strength Hip extensor strength Hip abductor strength Hip adductor strength Foot arch * Model (3,1) Model (2,1) Tester 1* 0.92 0.95 0.89 0.85 0.82 0.91 0.94 0.81 0.98 0.89 0.98 0.96 0.92 0.94 0.94 Tester 2* 0.89 0.91 0.86 0.84 0.72 0.91 0.93 0.78 Intertester 0.90 0.90 0.85 0.79 0.75 0.90 0.87 0.77

Therefore, these factors were analyzed separately for men and women. We used pooled data to compare means of the other variables, which had no significant health status by sex interaction effect. The chisquare analysis showed a significant difference (P = 0.04) in the length of the iliotibial band and no significant difference in the leg length discrepancy (P = 0.47) between the symptomatic and asymptomatic subjects. Back extensor endurance, the length of the hamstring muscles, iliotibial band tightness, back extensor muscle length, and the strength of the hip flexor, hip extensor, hip adductor, hip abductor and abdominal muscles were found to be significantly different between asymptomatic subjects and those with LBP. We used backward logistic regression analysis to determine the association between LBP and the variables, which showed a significant difference between subjects with and without LBP (back extensor endurance, hamstrings muscle length, iliotibial band tightness, back extensor muscle length, and hip flexor, hip extensor, hip adductor, hip abductor, and abdominal muscle strength). Both in pooled and separate data analysis for men and women, among all the factors that remained in the model, endurance of the back extensor muscles had the highest association with LBP (Figure 4). Some of the variables were eliminated from the model due to the fact that in logistic regression analysis when one variable is retained in the model, any other variable highly correlated with it will be eliminated from the model. In this study, for example, since hip flexor and hip adductor strengths were retained in the model, hip extensor and hip abductor strengths, which were highly correlated with them (Table 4), were eliminated.

RESEARCH REPORT

TABLE 3. Mean and standard deviation (SD) of the tested variables from 2 2 ANOVA table. Variables Lumbar lordosis () Back extensor length, men ()* Back extensor length, women ()* Iliopsoas length () Hip adductor length () Hamstrings length () Abdominal muscle length Foot arch Triceps surae length () Back extensor endurance, men (s)* Back extensor endurance, women (s)* Hip flexor strength (kPa) Hip extensor strength (kPa) Hip abductor strength (kPa) Hip adductor strength (kPa) Pelvic tilt () Abdominal muscle strength, men (kPa)* Abdominal muscle strength, women (kPa)* Asymptomatic 35 13 23 7 19 7 52 47 9 149 9 0.53 0.06 0.68 0.15 13 4 79 45 57 36 43 11 29 7 32 7 31 7 72 31 5 23 4 LBP 34 14 18 8 16 7 52 47 10 144 10 0.54 0.06 0.65 0.14 13 4 29 24 22 15 36 11 22 7 26 8 23 8 73 24 8 18 5 P Value 0.21 0.01 0.009 0.58 0.99 0.01 0.80 0.08 0.69 0.01 0.01 0.01 0.01 0.01 0.01 0.78 0.01 0.01

* These variables had a significant sex-by-health-status interaction at 0.05 level; therefore, they were analyzed separately for men and women. The other variables had no significant sex-by-health-status interaction; therefore, the comparison of means from the asymptomatic and the low back pain (LBP) group was conducted from the main effect of health status.

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125 100

-2LogLR

Pooled Males Females

75 50 25 0 BEXTend ABDOst BEXTlen HFst HADDst HAMlen

Factors

FIGURE 4. Degree of association between low back pain (LBP) and various physical characteristics. (BEXTend, back extensor muscle endurance; ABDOst, abdominal muscle strength; BEXTlen, back extensor muscle length; HFst, hip flexor muscle strength; HADDst, hip adductor muscle strength; HAMlen, hamstrings muscle length.) Among all the factors that had a significant association with LBP, endurance of the back extensor muscles showed the highest association. Contrary to the pooled data, the length of the hamstring muscles in men and women and the strength of the hip flexor and hip adductor muscles in women showed no significant association with LBP.

DISCUSSION Endurance of Back Extensor Muscles

Our data indicate that among all the physical characteristics measured, the endurance of the back ex-

tensor muscles has the highest association with LBP. This finding is in accordance with other studies showing a significant decrease in back extensor muscle endurance in patients with chronic LBP.3,50,51,53,59,63,103 Biering-Sorensen8 identified poor back extensor muscle endurance as an important risk factor for LBP. Others have suggested that a test of back extensor endurance be used as a screening tool in the selection of workers for strenuous jobs.17 Trunk extensors are classified as postural muscles.61 Because these muscles are rich in larger diameter type I muscle fibers,112 they are suited to support low levels of activity for long periods of time.85 Electromyographic (EMG) studies, however, indicate that the paraspinal muscles in patients with LBP have a faster fatigue rate compared with those in asymptomatic subjects.3,7,56,89,94,102 Investigators have attributed the decreased muscle endurance found in patients with LBP to various factors, such as higher muscle metabolite level resulting from prolonged muscle tension and spasm,2 higher proportion of type II muscle fibers in paraspinal muscles,101 muscle deconditioning,102 impaired muscle coordination and unequal distribution of back extensor muscle force,101 and inhibition and atrophy of the paraspinal muscles,102 especially the lumbar multifidus muscles,24,80 in response to pain and de-

TABLE 4. Correlation matrix (r values) among tested factors. (Values in bold have a P value of 0.05.) Back Hip Hip Hip Hip Lum- Exten- Iliop- Adduc- Ham- AbdomGastroc- Hip Exten- Abduc- AdducAbdombar sor soas tor strings inal Foot soleus Flexor sor tor tor Pelvic inal Lordosis Length Length Length Length Length Arch Length Strength Strength Strength Strength Tilt Strength 0.14 0.05 0.01 0.24 0.21 0.07 0.11 0.03 0.36 0.21 0.002 0.05 0.08 0.19 0.17 0.11 0.16 0.13 0.10 0.07 0.06 0.18 0.15 0.13 0.18 0.06 0.22 0.20 0.05 0.13 0.04 0.11 0.13 0.09 0.08 0.08 0.25 0.04 0.15 0.03 0.370.03 0.310.03 0.300.001 0.320.03 0.19 0.17 0.20 0.20 0.82 0.89 0.88 0.03 0.67 0.39 0.81 0.82 0.07 0.69 0.42 0.89 0.01 0.63 0.37 0.02 0.66 0.38 0.09 0.01 0.43

Variables Back extensor length Iliopsoas length Hip adductor length Hamstrings length Abdominal muscle length Foot arch Gastrocsoleus length Hip flexor strength Hip extensor strength Hip abductor strength Hip adductor strength Pelvic tilt Abdominal muscle strength Back extensor endurance

0.001 0.35 0.09 0.02 0.08 0.09 0.10 0.06 0.008 0.26 0.28 0.34 0.35 0.36 0.003 0.24 0.15

0.005 0.07 0.09 0.17 0.05 0.01

0.22 0.003 0.06 0.23 0.008 0.25 0.05 0.05 0.09

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creased activity.63 Hides et al48 showed a 31% decreased cross-sectional area in lumbar multifidus muscles in patients with LBP, which did not resolve automatically after remission of painful symptoms.47 According to Roy et al,101 these muscles consistently demonstrate a higher fatigue rate in patients with LBP. Wilder and Aleksiev122 showed that fatigued erector spinae muscles have a longer response time and decreased ability to tolerate sudden loads. Excessive uncontrolled loads may induce strain on the facet joints and the passive structure of the lumbar spine, resulting in LBP.20 The high association between the endurance of back extensor muscles and LBP found in our study complements the results of previous studies which indicated that improvement of erector spinae endurance is an important factor in preventing8 and treating86,95 LBP. Some investigators have recommended flexion exercises to decrease lumbar lordosis,66,76 and others have advocated extension exercises to increase lumbar lordosis28,92,95 in the treatment of LBP. The fact that flexion and extension exercises have the same effect on reducing LBP16,30,33,41,78,127 indicates that improved symptoms may be due to enhanced muscle endurance and coordination between the trunk flexor and extensor muscles50 rather than changes in the size of the lumbar lordosis.

LBP is a compensatory mechanism in response to tight hip flexor and weak gluteal and abdominal muscles. Although our data shows a significant but weak association between back extensor muscle length and hip extensor muscle strength (r = 0.15, P = 0.008) (Table 4), we found that the length of the hip flexors (r = 0.01, P = 0.83) and the strength of the abdominal muscles (r = 0.09, P = 0.08) were not associated with the length of the back extensor muscles. Our data showed a much stronger association between LBP and the endurance of the back extensor muscles than between LBP and the length of these muscles both in men and women (Table 5). It is suggested that back extensor muscle tightness in patients with LBP may be due to adaptive shortening of these muscles in response to muscle fatigue and overuse.

RESEARCH REPORT

Abdominal Muscle Strength

Similar to previous studies,3,44,73,83,88 our data indicate that patients with LBP have significantly lower abdominal muscle strength compared with asymptomatic subjects. It is commonly hypothesized that weak abdominal muscles cause anterior pelvic tilt and increased lumbar lordosis.18,61,65,123 Although a significant association between the strength of the abdominal muscles and LBP was found (Table 5), the data in our study did not support the stated hypothesis. In the study, the strength of the abdominal muscles was not correlated with the size of the lumbar lordosis (r = 0.07) or pelvic tilt (r = 0.09). Other investigators have also not associated the size of lumbar lordosis or pelvic tilt with the strength of the abdominal muscles.121,124 Levine et al75 found that an 8-week strengthening exercise program for the abdominal muscles increased muscle strength but had

Length of Back Extensor Muscles

The results of this study show a significantly lower flexibility of the back extensor muscles in subjects with LBP. Similar findings have been reported by others.14,52,70,117 Kendall65 believes that back extensor muscle tightness is due to abdominal muscle weakness and prolonged sitting posture. Norris91 stated that back extensor muscle tightness in patients with

TABLE 5. Degree of association between the tested variables and low back pain (LBP) from backward logistic regression analysis. Pooled Data Factors Back extensor endurance Back extensor length Abdominal muscle strength Hip flexor strength Hip adductors strength Hamstrings length 2LogLR 110.63 10.56 7.30 18.59 10.16 6.64 P Value 0.001 0.002 0.006 0.001 0.001 0.01 2LogLR 54.30 6.83 6.36 4.91 3.90 N/S Men P Value 0.001 0.008 0.01 0.02 0.04 2LogLR 62.93 7.11 20.2 N/S N/S N/S Women P Value 0.001 0.007 0.001

Among all the factors tested, the endurance of the back extensor muscles had the highest association with LBP. Originally, 9 factors were included in the model. The factors that had no significant association with LBP or were highly correlated with 1 of the retained variables were eliminated through backward logistic regression analysis. N/S indicates nonsignificant factors that were eliminated from the model. 2LogLR is an index in logistic regression showing the degree of association between each factor and LBP. The higher the value of 2LogLR, the higher the likelihood of that factor being associated with LBP.

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no effect on the size of the lumbar lordosis of the subjects. Moreover, the results of this study, in agreement with others,30,41,87,96 indicated that the size of the lumbar lordosis and pelvic tilt was not associated with LBP. More research is needed to describe the cause of abdominal muscle weakness in patients with LBP.

Hamstring Muscle Length

A logistic regression analysis, which accounted for sex effect, showed no significant association between the length of the hamstring muscles and LBP (Table 5). This finding is in accordance with Hellsing,45 who studied hamstrings tightness in 600 young men over a 4-year period and found no association between hamstrings tightness and LBP or the incidence of back pain during the follow-up period. This study and several others, however, showed a significant difference in hamstrings length between subjects with and without LBP.52,64,84 Because the hamstring muscles attach to the ischial tuberosity, it is hypothesized that tightness of these muscles may induce posterior pelvic tilt, resulting in a flat back and LBP.18,65,105 Our data, however, showed no significant association between the length of the hamstring muscles and pelvic tilt (r = 0.08) or the size of the lumbar lordosis (r = 0.11). Similar findings have been reported elsewhere.35,115 Moreover, the results of this study and others6,21,27,30,37,41,87,96,121,124 indicate that LBP is not associated with the size of the lumbar lordosis or pelvic tilt. Van Wingerden et al118 suggest that hamstrings tightness in patients with LBP is a compensatory mechanism secondary to pelvic instability. Considering these findings, the stated hypothesis regarding the effect of hamstrings tightness on LBP requires re-evaluation.

length of these muscles and LBP. Our data, however, showed a statistically significant association between the strength of the hip flexor muscles and LBP in men (Table 5). Hip flexors in subjects with LBP were significantly weaker than in those without LBP. Bachrach4 believes that laxity and mechanical instability in the lumbosacral area due to iliopsoas muscle weakness can stimulate nociceptors in the surrounding soft tissue, resulting in pain. The reason that our data did not show a significant relationship between LBP and hip flexor muscle strength in women may be due to the data analysis used. Backward logistic regression analysis maintains the factors with the strongest association with the dependent variable in the model and eliminates the rest. When all the factors were included in the model, the strength of the hip flexor muscles had a significant association with LBP in both women (2LogLR = 7.44, P = 0.006) and men (2LogLR = 7.15, P = 0.007). Separate data analysis for men and women, however, showed that in women, the strength of the abdominal muscles and the endurance and length of the back extensor muscles accounted for greater variability of data than they did in men (Figure 4). Therefore, hip flexor strength was eliminated as a weak variable in women. In men, the stated factors accounted for less variability of data, allowing hip flexor strength to remain in the model as a factor significantly correlated with LBP (Table 5).

CONCLUSION
It appears that muscle weakness is associated with LBP and that structural factors, such as the size of the lumbar lordosis, pelvic tilt, foot arch, leg length difference, and the length of abdominal, iliopsoas, triceps surae, and hip adductor muscles, are not associated with LBP. Our data show no difference in these structural factors between subjects with and without LBP and showed no association between these factors and LBP. We assume, as also stated by others,50,72 that decreased back extensor muscle endurance is an important factor in chronic LBP. We agree with other investigators who have proposed increased activity and endurance exercises to reduce the occurrence of LBP.47,93,98,104

Hip Flexor Muscles

By virtue of iliopsoas attachment to the pelvis and lumbar spine, some investigators have assumed that tightness of this muscle affects the size of the lumbar lordosis and causes LBP.18,65,97,105 Biomechanical analysis has revealed that the iliopsoas muscle, which generates significant compressive forces, exerts very small rotatory movement on the vertebrae and has no substantial action on the lumbar spine.9 Other studies investigating this assumption have found no association between iliopsoas muscle length and lumbar lordosis60,116,124 or LBP.4 In agreement with the literature, this study found no significant association between the size of the lumbar lordosis (r = 0.05) or pelvic tilt (r = 0.07) and the length of the hip flexor muscles in subjects with LBP. Furthermore, no significant difference was found in the length of the hip flexor muscles between subjects with and without LBP, and no association was found between the
456

ACKNOWLEDGMENT
The authors would like to thank Ms. Kathy Gannon for assistance in preparing this manuscript.

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This article has been cited by: 1. D. Scott Davis, Corrie A. Mancinelli, John J. Petronis, Calvin Bensenhaver, Travis McClintic, George Nelson. 2013. Variables Associated With Level of Disability in Working Individuals With Nonacute Low Back Pain: A Cross-sectional Investigation. Journal of Orthopaedic & Sports Physical Therapy 43:2, 97-104. [Abstract] [Full Text] [PDF] [PDF Plus] 2. Amity C. Campbell, Andrew M. Briggs, Peter B. O'Sullivan, Anne J. Smith, Angus F. Burnett, Penny Moss, Leon M. Straker. 2011. An Exploration of the Relationship Between Back Muscle Endurance and Familial, Physical, Lifestyle, and Psychosocial Factors in Adolescents and Young Adults. Journal of Orthopaedic & Sports Physical Therapy 41:7, 486-495. [Abstract] [Full Text] [PDF] [PDF Plus] 3. Yung-Shen Tsai, Timothy C. Sell, James M. Smoliga, Joseph B. Myers, Kenneth E. Learman, Scott M. Lephart. 2010. A Comparison of Physical Characteristics and Swing Mechanics Between Golfers With and Without a History of Low Back Pain. Journal of Orthopaedic & Sports Physical Therapy 40:7, 430-438. [Abstract] [Full Text] [PDF] [PDF Plus] 4. Richard A. Ekstrom, Robert A. Donatelli, Kenji C. Carp. 2007. Electromyographic Analysis of Core Trunk, Hip, and Thigh Muscles During 9 Rehabilitation Exercises. Journal of Orthopaedic & Sports Physical Therapy 37:12, 754-762. [Abstract] [PDF] [PDF Plus] 5. Barbara J. Norton, Shirley A. Sahrmann, Linda R. Van Dillen. 2004. Differences in Measurements of Lumbar Curvature Related to Gender and Low Back Pain. Journal of Orthopaedic & Sports Physical Therapy 34:9, 524-534. [Abstract] [PDF] [PDF Plus]