Clinical measures of balance and gait cannot differentiate somatosensory impairments in people with lower-limb amputation.

BACKGROUND: In addition to a range of functional impairments seen in individuals with a lower-limb amputation, this population is at a substantially elevated risk of falls. Studies postulate that the lack of sensory feedback from the prosthetic limb contributes heavily to these impairments, but the extent to which sensation affects functional measures remains unclear. RESEARCH QUESTION: The purpose of this study is to determine how sensory impairments in the lower extremities relate to performance with common clinical functional measures of balance and gait in individuals with a lower-limb amputation. Here we evaluate the effects of somatosensory integrity to clinical and lab measures of static, reactive and dynamic balance, and gait stability. METHODS: In 20 individuals with lower-limb amputation (AMP) and 20 age and gender-matched able-bodied controls (CON), we evaluated the effects of sensory integrity (pressure, proprioception, and vibration) on measures of balance and gait. Static, reactive, and dynamic balance were assessed using the Sensory Organization Test (SOT), Motor Control Test (MCT), and Functional Gait Assessment (FGA), respectively. Gait stability was assessed through measures of step length asymmetry and step width variability. Sensation was categorized into intact or impaired sensation by pressure thresholds and differences across groups were analyzed. RESULTS: There were significant differences between AMP and CON groups for reliance on vision for static balance in the SOT, MCT, and FGA (p < 0.01). Despite differences across groups, there were no significant differences within the AMP group based on intact or impaired sensation across all functional measures. SIGNIFICANCE: Despite being able to detect differences between able-bodied individuals and individuals with an amputation, these functional measures cannot distinguish between levels of impairment within participants with an amputation. These findings suggest that more challenging and robust metrics are needed to evaluate the effects of sensation and function in individuals with an amputation.

Community-dwelling adults with a history of falling report lower perceived postural stability during a foam eyes closed test than non-fallers.

Perceived postural stability has been reported to decrease as sway area increases on firm surfaces. However, changes in perceived stability under increasingly challenging conditions (e.g., removal of sensory inputs) and the relationship with sway area are not well characterized. Moreover, whether perceived stability varies as a function of age or history of falls is unknown. Here we investigate how perceived postural stability is related to sway area and whether this relationship varies as a function of age and fall history while vision and proprioceptive information are manipulated. Sway area was measured in 427 participants from the Baltimore Longitudinal Study of Aging while standing with eyes open and eyes closed on the floor and a foam cushion. Participants rated their stability [0 (completely unstable) to 10 (completely stable)] after each condition, and reported whether they had fallen in the past year. Perceived stability was negatively associated with sway area (cm2) such that individuals who swayed more felt less stable across all conditions (ß = - 0.53, p < 0.001). Perceived stability decreased with increasing age (ß = - 0.019, p < 0.001), independent of sway area. Fallers had a greater decline in perceived stability across conditions (F = 2.76, p = 0.042) compared to non-fallers, independent of sway area. Perceived postural stability declined as sway area increased during a multisensory balance test. A history of falling negatively impacts perceived postural stability when vision and proprioception are simultaneously challenged. Perceived postural stability may provide additional information useful for identifying individuals at risk of falls.

Interpersonal interactions for haptic guidance during balance exercises.

BACKGROUND: Caregiver-patient interaction relies on interpersonal coordination during support provided by a therapist to a patient with impaired control of body balance. RESEARCH QUESTION: The purpose of this study was to investigate in a therapeutic context active and passive participant involvement during interpersonal support in balancing tasks of increasing sensorimotor difficulty. METHODS: Ten older adults stood in semi-tandem stance and received support from a physical therapist (PT) in two support conditions: 1) physical support provided by the PT to the participant's back via an instrumented handle affixed to a harness worn by the participant ("passive" interpersonal touch; IPT) or 2) support by PT and participant jointly holding a handle instrumented with a force-torque transducer while facing each other ("active" IPT). The postural stability of both support conditions was measured using the root-mean-square (RMS) of the Centre-of-Pressure velocity (RMS dCOP) in the antero-posterior (AP) and medio-lateral (ML) directions. Interpersonal postural coordination (IPC) was characterized in terms of cross-correlations between both individuals' sway fluctuations as well as the measured interaction forces. RESULTS: Active involvement of the participant decreased the participant's postural variability to a greater extent, especially under challenging stance conditions, than receiving support passively. In the passive support condition, however, stronger in-phase IPC between both partners was observed in the antero-posterior direction, possibly caused by a more critical (visual or tactile) observation of participants' body sway dynamics by the therapist. In-phase cross-correlation time lags indicated that the therapist tended to respond to participants' body sway fluctuations in a reactive follower mode, which could indicate visual dominance affecting the therapist during the provision of haptic support. SIGNIFICANCE: Our paradigm implies that in balance rehabilitation more partnership-based methods promote greater postural steadiness. The implications of this finding with regard to motor learning and rehabilitation need to be investigated.

Vestibular rehabilitation using a wide field of view virtual environment.

This paper presents a theoretical justification for using a wide field of view (FOV) virtual reality display system for use in vestibular rehabilitation. A wide FOV environment offers some unique features that may be beneficial to vestibular rehabilitation. Primarily, optic flow information extracted from the periphery may be critical for recalibrating the sensory processes used by people with vestibular disorders. If this hypothesis is correct, then wide FOV systems will have an advantage over narrow field of view input devices such as head mounted or desktop displays. Devices that we have incorporated into our system that are critical for monitoring improvement in this clinical population will also be described.

The steady-state postural response to continuous sinusoidal galvanic vestibular stimulation.

Galvanic vestibular stimulation (GVS) applied between the mastoids during quiet standing elicits postural sway. The aim of this study was to characterize the postural sway response to continuous sinusoidal GVS across various stimulus frequencies and amplitudes. Binaural bipolar sinusoidal GVS was applied to the skin overlying the mastoid processes of 10 subjects while they stood on a force plate with eyes closed. The position of the center of pressure (COP) at the feet was recorded from a forceplate, while the head displacement was measured with a magnetic position tracking system. The stimulus conditions included four frequencies (0.1, 0.25, 0.45, and 1.1 Hz) and five peak amplitudes (0.05, 0.1, 0.25, 0.5, and 1.0 mA). Each subject experienced one trial at each amplitude-frequency pair. Additionally, each subject underwent three trials in which a dual-frequency stimulus (0.1 plus 0.45 Hz at a peak of 0.5 mA each) was presented. The stimuli elicited sway in the frontal plane in all subjects, as evidenced by changes in the displacement of the COP and head. Sway magnitude decreased with increasing stimulus frequency and increased with increasing stimulus amplitude. However, the response magnitude saturated at higher stimulus amplitudes. Phase lag increased with increasing stimulus frequency. The response to the dual-frequency stimulus was reduced at 0.1 Hz and nearly equal at 0.45 Hz in comparison with the single-frequency responses. This study suggests that the postural sway response is nonlinear due to saturation and violation of the principle of superposition.

Generalizability of trunk muscle EMG and spinal forces.

The generalizability of trunk muscle EMG and spinal loading estimates obtained from an EMG-assisted biomechanical model was assessed over three occasions and three repetitions. The greatest sources of variability consisted of the intersubject differences and the interaction between subject and occasion. The ID (reliability coefficient) was less for trunk muscle activity compared with estimates of anteroposterior shear force, compression force, and gain computed from the biomechanical model. In order to obtain an ID of 0.8, we recommend five testing occasions for submaximal EMG measurements and three testing occasions for biomechanical estimates. Reproducible estimates of maximal trunk extensor EMG could not be obtained within five testing occasions and five repetitions. Although many recruitment patterns could cause the same extension torque output, their net effect on internal loading seems to be less variable than the underlying measurements.

Wavelet and short-time Fourier transform analysis of electromyography for detection of back muscle fatigue.

Measurement of the time-varying characteristics of the frequency content of trunk muscle electromyography is a method to quantify the amount of fatigue endured by workers during industrial tasks, as well as a tool that may guide the training and rehabilitation of healthy and injured workers. Quantification of the change of signal power within specific frequency ranges may shed greater insight into the fatigue process. Sixteen healthy male subjects performed isometric trunk extension at 70% of their maximum voluntary contraction. Surface electromyography from medial and lateral erector spinae, and latissimus dorsi locations were processed using the short-time Fourier transform (STFT) and wavelet transform. Linear regression quantified the time rate of change of median frequency as well as frequency specific STFT filter and wavelet scale measures. The median frequency from the short-time Fourier transform declined by 22 Hz/min from an initial value of 77 Hz on average. The wavelet and STFT filter measures demonstrated this decline to be caused by a reduction in 209-349 Hz signal power in addition to an increase in 7-88 Hz signal power. A significant reduction in median frequency and significant elevation in 13-22 Hz wavelet signal component was detected in about 90% of the cases, indicating their use for detecting and quantifying fatigue.

Cervicogenic dizziness: a review of diagnosis and treatment.

The diagnosis of cervicogenic dizziness is characterized by dizziness and dysequilibrium that is associated with neck pain in patients with cervical pathology. The diagnosis and treatment of an individual presenting with cervical spine dysfunction and associated dizziness complaints can be a challenging experience to orthopaedic and vestibular rehabilitation specialists. The purpose of this article is to review the incidence and prevalence, historical background, and proposed pathophysiology underlying cervicogenic dizziness. In addition, we have outlined the diagnostic criteria, evaluation, and treatment of dizziness attributed to disorders of the cervical spine. The diagnosis of cervicogenic dizziness is dependent upon correlating symptoms of imbalance and dizziness with neck pain and excluding other vestibular disorders based on history, examination, and vestibular function tests. When diagnosed correctly, cervicogenic dizziness can be successfully treated using a combination of manual therapy and vestibular rehabilitation. We present 2 cases, of patients diagnosed with cervicogenic dizziness, as an illustration of the clinical decision-making process in regard to this diagnosis.

An electromyography-assisted model to estimate trunk muscle forces during fatiguing repetitive trunk exertions.

During submaximal shortening muscle contraction, fatigue characteristically results in an increase in measured surface electromyography, whereas the maximum force that can be produced by muscle is reduced. This finding compromises researchers' ability to estimate muscle stress in a joint system such as the spine, which is composed of more muscles than degrees of freedom of the joint. A three-dimensional, electromyography-assisted, dynamic biomechanical model of spinal loading was developed and validated for use during fatiguing repetitive trunk extension exertions. A time-varying maximum muscle stress was included to model the effect of a change in the maximum force-producing capacity of the erector spinae muscle. Sixteen men performed submaximal isokinetic trunk extension endurance tests at 15 degrees per second. The exertion level (35% and 70% of their maximum dynamic extension torque) and repetition rate (5 and 10 repetitions per minute) of the tests were varied during four testing sessions. Using trunk muscle electromyography and the measured torque as input, the model predicted significant linear reductions in the maximum muscle stress in 78% of the endurance tests, which resulted in an estimated decrease in erector spinae force in 75% of the tests. Conversely, if the maximum muscle stress was assumed to be constant, the erector spinae force would have been predicted to increase in 73% of the tests. The magnitude of the change in predicted erector spinae maximum muscle stress and force depended on the exertion level and repetition rate. This model will allow researchers to assess the effects of changes in recruitment patterns of trunk muscles during dynamic trunk extension on the estimated spinal loading of the lumbar spine.

Wavelet analysis of electromyography for back muscle fatigue detection during isokinetic constant-torque exertions.

STUDY DESIGN: An investigation of the effects of human trunk extensor muscle fatigue on the temporal change in frequency content of the electromyogram as quantified using the Fourier and wavelet transforms during the performance of repetitive dynamic trunk extension. OBJECTIVE: To evaluate whether alterations in the Fourier and wavelet transform measures were consistent with a shift of the signal power to lower frequencies, and to determine which measures were more highly correlated with the decline in maximal trunk extension torque. SUMMARY OF BACKGROUND DATA: Objective assessment of trunk muscle fatigue is likely to play a more important role in the rehabilitation and prevention of low back injuries, given the association between lack of trunk muscle endurance and acquisition of low back pain. Validation of new methods designed to quantify the level of fatigue using the surface electromyogram is necessary before these techniques can be used in industrial rehabilitation settings. The wavelet transform is a recent development in the signal processing of electromyograms that shows promise as a method for assessment of fatigue. METHODS: Trunk muscle electromyograms obtained from study participants performing repetitive isokinetic trunk extension endurance tests were analyzed using the wavelet and the traditional Fourier methods. Trunk extension torque was controlled at 35% and 70% of the participants' maximal voluntary contraction while they exerted at 5 and 10 repetitions per minute. The decline in maximal trunk extension torque was measured once per minute. Linear regression quantified the rate of change in Fourier and wavelet measures caused by fatigue, whereas Pearson's correlation coefficient determined their association with the decline in maximum torque. RESULTS: Changes in the characteristics of the electromyogram were consistent with a shift to lower frequencies: The signal power at higher frequencies was reduced, whereas the power at lower frequencies was elevated. The amount of change was dependent on the task conditions (exertion level and repetition rate). The wavelet-based measures demonstrated as strong an association with the decline in maximal torque output as the Fourier-based measures. CONCLUSIONS: This study demonstrates that assessment of trunk muscle fatigue during isokinetic movementis possible using both Fourier and wavelet measurements. However, the methods were not as likely to change significantly during lower rates of exertion. These methods, when implemented in a controlled setting, may be used to document the rehabilitation process and guide preventive exercise training.

Feature extraction and quantification of the variability of dynamic performance profiles due to the different sagittal lift characteristics.

Investigation of manual material handling (MMH) tasks, such as lifting, requires the quantification of the various kinematic and kinetic parameters of performance for assessment of the functional capacity and/or task demand profiles. Traditional statistical descriptive analyses usually involve computing the summary statistics (maximum, minimum, mean, and/or range) of the resulting performance parameters over the cycle duration (i.e., lifting/lowering cycle). Consequently, the significant information content of the time-varying signals is diminished, limiting the sensitivity of subsequent hypothesis testing procedures. The present study developed a methodology for representing and quantifying performance data variability of the kinematic and kinetic motion profiles due to the different lift characteristics (load, mode, and speed) during MMH tasks while capturing the temporal characteristics. Using a database of motion profiles from a manual lifting experiment, the Karhunen-Loeve Expansion (KLE) feature extraction technique was shown to be quite effective for representing the various motion profiles. The number of basis vectors (eigenvectors) and corresponding coefficients needed for accurate representation were substantially smaller than the original data set, resulting in data compression. Moreover, the effects of lift characteristics were investigated using analysis of variance techniques that recognize the vectorial constitution of the waveforms. The application of these techniques will enable the quantification of highly phasic profiles and enhance the ability to document the effect of intervening measures such as educational or physical training/exercise on the kinematic and kinetic patterns of performance. Additionally, the differential influence of lift characteristics on the variability of performance during different phases of lifting and lowering provides added resolution in the analysis of MMH tasks.

Determination of the effect of lift characteristics on dynamic performance profiles during manual materials handling tasks.

In any quantitative gait or occupational biomechanics investigation, the quantification of the different kinematic, kinetic, and electromyographic parameters is essential towards assessment of functional capacity and development of a biomechanical profile of the task demands. In the current study, the authors presented a methodology for using inferential statistics to evaluate the effect of lift characteristics on phase-dependent and phase-independent variability in performance. Using a database of kinematic and kinetic profiles obtained from a manual lifting study, the phase-dependent effects of lift characteristics: box mass (load), mode (technique of lift), and speed (frequency of lift) were investigated through the use of analysis of variance (ANOVA) techniques, which recognize the vectorial constitution of the profiles. In addition, the Karhunen-Loeve Expansion (KLE) feature extraction method was used for representing the lifting patterns of measured joint angular position, velocity, acceleration, and net muscular torque profiles obtained from a 2-D biomechanical lifting model in order to study the phase-independent effects. In comparison to traditional descriptive statistical analyses currently used in various occupational biomechanics experimental investigations, this method allows the significant information content of the time varying signal to be captured, enhancing the sensitivity of subsequent hypothesis testing procedures. The application of this technique to MMH investigations allows identification of the lift characteristics that dominate the variability of task demands, hence aiding in the design and assessment of ergonomic solutions.

Estimation of trunk muscle forces and spinal loads during fatiguing repetitive trunk exertions.

STUDY DESIGN: The effects of human trunk extensor muscle fatigue on the estimated trunk muscle forces and spinal loading were investigated during the performance of repetitive dynamic trunk extension. OBJECTIVE: To evaluate if alterations in the trunk muscle recruitment patterns resulted in a greater estimated active loading of the spine and, in turn, an increased risk of injury. SUMMARY OF BACKGROUND DATA: Epidemiologic studies highlight the increased risk of low back injury during repetitive lifting, implicating fatigue of muscles and/or passive tissues as causes of such injury. Increased trunk muscle activity or altered recruitment patterns resulting from fatigue in the primary trunk extensor muscles may indicate an increase in the active loading of the spine, which could contribute to an increased risk of injury. METHODS: Sixteen healthy study participants performed repetitive isokinetic trunk extension endurance tests at two load levels and two repetition rates, while their net muscular torque output and trunk muscular activity were measured. During each exertion, trunk torque, position, and velocity were controlled, so that any change in muscle activity could be attributed to fatigue. An electromyography-assisted model, adapted to accommodate the decline in maximum muscular tension generation resulting from fatigue, was used to estimate the 10 trunk muscle forces and spinal loading. Linear regression was used to quantify the rate of change in muscle force and spinal loading resulting from fatigue, while analysis of variance was used to determine if the rate of change was dependent on the task conditions (load and repetition rate). RESULTS: Significant elevations were estimated for the latissimus dorsi and external oblique muscle forces in more than 70% of the endurance tests, whereas significant reductions in the erector spinae muscle force were predicted in 75% of the trials. The magnitude of the range of change of the erector spinae and latissimus dorsi muscle forces was dependent on the load level and repetition rate. The reduction in erector spinae forces offset the augmented force in the other muscles, because the net changes in compression and lateral shear forces on the spine were not significant, and the anteroposterior shear was reduced. CONCLUSION: The results of the study do not suggest that an increase in the muscular loading of the spine occurs as a result of changing trunk muscular recruitment patterns. Therefore, future studies should focus on injury mechanisms that may occur as a result of a change in the viscoelastic passive tissue responses, muscular insufficiency, or a decline in neuromuscular control and coordination.

The effect of lifting belt use on multijoint motion and load bearing during repetitive and asymmetric lifting.

The evaluation of the effect of lifting belts on multijoint coordinated lifting performance has been limited. Thirteen subjects participated in two experiments: (a) fatiguing repetitive sagittal lifting and (b) asymmetric lifting. Both experiments were performed with and without the use of a common flexible lifting belt to determine the effect of belt use on the trunk and lower extremity motion and load sharing. During both tests, the use of the belt was observed to restrict the sagittal trunk range of motion and velocity, while the hip motion and velocity increased. Although one of the risk factors for acquisition of low back pain may be reduced while wearing the belt, the results also demonstrate a need for greater study of the consequences on the risk of injury to the other joints. More laboratory experiments and prospective epidemiological studies are needed before a conclusive recommendation could be made in favor of using the belt as a valid preventive measure.

Effect of electromyogram-force relationships and method of gain estimation on the predictions of an electromyogram-driven model of spinal loading.

STUDY DESIGN: An experimental study of fatiguing isometric trunk extension was conducted to investigate the spinal loading estimated from an electromyogram-assisted biomechanical model. OBJECTIVE: To evaluate the sensitivity of the model outputs to two crucial assumptions: electromyogram-force relationship and method of gain estimation. SUMMARY OF BACKGROUND DATA: In the proposed electromyogram-assisted models of the trunk, the nature of the electromyogram-force relationship and the wide variation in reported muscle gains can result in a wide variation in estimates of spinal loading. Given the absence of any gold standard for validation of muscle forces, the delineation of confidence intervals for the estimated loads has become critical. METHODS: Ten subjects performed a fatiguing isometric trunk extension while the net muscular torque output and trunk muscular activity were measured. An electromyogram-assisted model was used to estimate the torque output and spinal loading. Linear and nonlinear erector spinae electromyogram-force relationships and three methods for gain estimation were investigated: constant gain determined from an initial maximum extension exertion, constant gain based on the fatiguing exertion, and a time-varying gain from the fatigue test. RESULTS: The predicted torque was not sensitive to the electromyogram-force relationship; the nonlinear model produced 10% lower estimates of peak spinal compression force and 14% higher estimates of peak anterior shear force. The gain determined from an initial calibration exertion underestimated the external torque and underpredicted the peak compression force by 20%, compared with gains calculated in the fatigue test. CONCLUSION: The nature of the electromyogram-force relationship and of the method for estimating the gain significantly affect the outcomes of an electromyogram-assisted model of spinal loading.

The effect of fatigue on multijoint kinematics and load sharing during a repetitive lifting test.

STUDY DESIGN: A repetitive lifting test in the sagittal plane was performed with a submaximal load at a maximal lifting rate to understand the effects of fatigue on kinematic and kinetic measures of performance. OBJECTIVES: To quantify the effect of fatigue during a highly repetitive lifting task, in terms of lifting force transmitted to the load, joint motion patterns, and internal joint load sharing. SUMMARY OF BACKGROUND DATA: Industrial surveillance and epidemiologic data suggest that repetitive lifting is a risk factor for low back pain. Previous studies examining the effect of fatigue have either been constrained to isolated trunk movement, or have not explored the internal load distribution and potential alteration in the loading patterns. METHODS: Sixteen healthy male subjects performed repetitive lifting in the sagittal plane with a load equal to 25% of their maximal lifting capacity, at a maximal lifting rate. Changes in lifting performance were determined from the power transferred to the box, joint kinematics, and joint kinetics. Data from three cycles at the start and end of the exercise were tested for the effect of fatigue using repeated-measures analysis of variance. RESULTS: Fatigue was documented by a reduction in average lifting force and hip and spine torque generation, whereas internal joint load sharing was relatively unchanged. The fatigue was associated with decreased knee and hip motion, and increased lumbar flexion. Decreased postural stability also was evident. CONCLUSIONS: The significant decrease in postural stability and force generation capability because of the repetitive lifting task indicated a higher risk of injury in the presence of unexpected perturbation. Multijoint coordinated lifting tasks provide a more realistic protocol to study neuromuscular fatigue.

Modeling of functional trunk muscle performance: interfacing ergonomics and spine rehabilitation in response to the ADA.

The combination of increasing costs of musculoskeletal injuries and the implementation of the Americans with Disabilities Act (ADA) has created the need for a more objective functional understanding of dynamic trunk performance. In this study, trunk extensor and flexor strengths were measured as a function of angular position and velocity for 20 subjects performing maximum isometric and isokinetic exertions. Results indicate that trunk strength is significantly influenced by trunk angular position, trunk angular velocity, gender, and direction, as well as by the interaction between trunk angular position and velocity. Three-dimensional surfaces of trunk strength in response to trunk angular position and velocity were constructed for each subject per direction. Such data presentation is more accurate and gives better insight about the strength profile of an individual than does the traditional use of a single strength value. The joint strength capacity profiles may be combined with joint torque requirements from a manual material handling task, such as a lifting task, to compute the dynamic utilization ratio for the trunk muscles. This ratio can be used as a unified measure of both task demand and functional capacity to guide job assignment, return to work, and prognosis during the rehabilitation processes. Furthermore, the strength regressions developed in this study would provide dynamic strength limits that can be used as functional constraints in the computer simulation of physical activities, such as lifting. In light of the ADA, this would be of great value in predicting the consequences of task modifications and/or workstation alterations without subjecting an injured worker or an individual with a disability to unnecessary testing.

Neuromuscular trunk performance and spinal loading during a fatiguing isometric trunk extension with varying torque requirements.

A novel testing protocol was used to investigate changes in neuromuscular performance, muscle recruitment, and spinal loading as subjects became fatigued while performing an isometric endurance test of varying torque requirements. There was decreased accuracy in maintenance of a reference torque but no change in response time as subjects became fatigued. The study of trunk-muscle recruitment indicated significant increases in internal oblique and latissimus dorsi muscle activity. This change in recruitment led to changes in spinal loading despite a relatively constant torque output. The use of an electromyogram (EMG)-assisted model demonstrated that when subjects are expected to become fatigued during test performance, the assumption of a constant maximal stress capacity of the muscle may not be robust.

Spectral and temporal responses of trunk extensor electromyography to an isometric endurance test.

STUDY DESIGN: This study investigated the effect of trunk extensor muscle location on the spectral and temporal electromyographic activity of the muscles during a fatiguing isometric extension of the torso against gravity. OBJECTIVES: To determine the spectral responses of the trunk extensor muscles at more locations than have been studied previously, to determine if fatigue in the knee flexors limits this test, and to quantify the recruitment patterns of the trunk extensor muscles in a group of healthy subjects. SUMMARY OF BACKGROUND DATA: Isometric endurance tests appear to have more value than strength tests in predicting the occurrence of low back pain. Electromyographic activity of trunk extensor muscles during these tests may provide clues to the etiology of neuromuscular-based low back pain. Spectral electromyographic measures appear to be successful discriminators between low back pain patient and normal populations, although which muscles provide the best information is unclear. Likewise, the recruitment patterns of the trunk extensors during fatiguing isometric tasks is not well quantified. METHODS: Ten healthy men performed an isometric trunk endurance test. Surface electromyography was recorded from the erector spinae medially and laterally at vertebral levels of L1 and L3, medially at L5, and from the biceps femoris and gastrocnemius. Spectral parameters were calculated from the Fast Fourier Transform, and temporal parameters were calculated from the root mean square of the raw data. Linear regression was used to determine their responses as a function of time. RESULTS: There was a significant effect of vertebral level and medial-lateral location on the initial median frequency and linear slope of the median frequency regressions. No significant evidence of fatigue in the lower extremities was observed. For most subjects, the temporal response of the surface electromyography was parabolic (concave-down), peaking at 30-50% of the endurance time. CONCLUSION: Establishment of which muscle locations provide the best information and knowledge of the recruitment patterns are essential for the development of clinical diagnostic procedures and rehabilitation protocols.

The effect of fatigue on multijoint kinematics, coordination, and postural stability during a repetitive lifting test.

Because of the inability of strength tests to accurately discriminate between low back pain patients and healthy subjects, a multifactorial evaluation of low back pain patients is warranted. It is postulated that measurements of endurance, kinematics, postural stability, and coordination, in addition to strength, are necessary to fully document the patients' functional capabilities. This research study was conducted in order to understand the effects of fatigue on the above factors. Twelve healthy male subjects performed a repetitive lifting test in which a submaximal load was lifted at a maximal rate. Knee, hip, and trunk motion was measured using videography and electrogoniometry, postural stability was measured using a forceplate, and coordination parameters were determined using phase-plane analysis. Fatigue was documented by a 31% reduction in lifting power. At the end of the endurance test, there was less knee and hip range of motion and greater spine peak flexion, while the coordination measures demonstrated that there was greater hip and lumbar spine extension earlier in the lifting phase. The postural stability declined as the test endured. Utilization of these measures may guide physical therapists in their rehabilitation of low back pain patients.