Is Poor Trunk Postural Control a Risk Factor for Low Back Pain?

Welcome to Chi-research. A weekly publication by ProCredits reviewing current research associated with the Chiropractic profession. In this week’s edition, we are reviewing a 2024 article using meta-analysis to evaluate the quality of trunk postural control in patients with and without low back pain (LBP).

Trunk postural control is the capacity to maintain both postural equilibrium (control of the center of mass over the base of support) and postural orientation between segments (within spine regions and between the spine and other body regions). Therefore, it is critical for executing human motion and completing everyday activities. Trunk postural control is not simply core strength, it requires motor skill, the integration of kinematic (position and movement) feedback from visual, vestibular, and proprioceptive systems, and the generation of coordinated motor responses using an array of muscles.

Low back pain (LBP) is a multifactorial condition and is the leading cause of disability globally. Many times, it is of insidious onset with no pinpoint trauma or cause preceding it. The quality of trunk postural control has been suggested as a risk factor for LBP development, recurrence, and/or perpetuation, mediated by effects of suboptimal loading on spine tissue, and may be an explanation for this common insidious cause.

How do we measure the quality of someone’s postural control? Many studies use an unstable sitting paradigm to assess the contribution of the trunk to postural control by limiting contributions from the legs and arms. To maintain balance in this paradigm, the global position of the upper body is maintained via dynamic movements at the base/seat.

Movements at the base/seat are attenuated by coordinated movements of the hip and spine to limit upper body movements and maintain the overall center of mass close to the center of pressure (the location of the point of contact of the seat). Many outcome measures from this paradigm have been reported to have acceptable to excellent test-retest reliability for assessing trunk postural control among individuals with or without LBP.

Poor Trunk Postural Control

In today’s study, Trunk postural control during unstable sitting among individuals with and without low back pain: A systematic review with an individual participant data meta-analysis. The authors analyzed 64 studies with 2871 participants to determine whether trunk postural control differs between those with and without LBP and whether the difference between groups is impacted by vision and potential confounding factors.

This systematic review indicated that trunk postural control differs between individuals with and without LBP in that individuals with LBP demonstrated poorer postural control of the trunk. Second, meta-analyses revealed that trunk postural control deteriorates more from removal of vision among individuals with than without LBP. Third, meta-analyses revealed that older age and higher BMI have greater adverse impacts on trunk postural control among individuals with than without LBP.

Why do LBP patients demonstrate poorer postural control? Decreased sense of lumbar proprioception, increased trunk stiffness, and delayed onset or offset of trunk muscle activity are commonly seen in patients with LBP. Some plausible mechanisms may include the fact that those with LBP have less proprioceptive sensitivity which may reduce the ability to coordinate or delay the trunk muscle response required to maintain balance affecting not only the accuracy and precision of trunk movement but also the detection of movement errors required to execute postural adjustments.

Alternatively, some LBP patients may adopt a distinct muscle activation strategy to control balance, such as increased muscle co-activation, either to reduce reliance on proprioception or to protect the spine from threats resulting in trunk stiffness. Corrective adjustments for postural control require contributions of the visual, vestibular, and senses as indicated by the fact that decreased trunk postural control was seen in the absence of visual feedback but was even greater for individuals with than without LBP. 

The authors concluded that there is robust evidence that trunk postural control is compromised among individuals with LBP, however, they cannot discriminate whether changes in trunk postural control are a cause or consequence of LBP. Regardless, impaired trunk postural control should be diagnosed and treated as both a prophylactic mechanism to avoid insidious LBP as well as part of an active care plan for those suffering from LBP as well.

How do we improve trunk postural control? There are many exercises that can be performed in the office or at home from beginner to advanced to improve trunk postural control. Starting with simple movements with intention and control of the core and progressing to more difficult exercises using unstable surfaces is imperative for improved function and patient challenge which will increase patient compliance.

Below are courses that ProCredits offers that help the clinician diagnose and treat patients with and without LBP to improve trunk postural control.

Evaluation and Management of Low Back Conditions Level 2: Spinal Biomechanics

Evaluation and Management of Low Back Conditions Level 2: Evaluation and Treatment

Essentials of Lumbar Spine Rehab

 Trunk postural control during unstable sitting among individuals with and without low back pain: A systematic review with an individual participant data meta-analysis

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References

Alshehri MA, Alzahrani H, van den Hoorn W, Klyne DM, Vette AH, et al. (2024) Trunk postural control during unstable sitting among individuals with and without low back pain: A systematic review with an individual participant data meta-analysis.