Accepted Manuscript Is there a relationship between lumbar proprioception and low back pain? A systematic review with meta-analysis Matthew Hoyan Tong, BAppSc, Seyed Javad Mousavi, PhD, Henri Kiers, PhD, Paulo Ferreira, PhD, Kathryn Refshauge, PhD, Jaap van Dieën, PhD PII:
S0003-9993(16)30245-3
DOI:
10.1016/j.apmr.2016.05.016
Reference:
YAPMR 56576
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 5 January 2016 Revised Date:
8 April 2016
Accepted Date: 16 May 2016
Please cite this article as: Tong MH, Mousavi SJ, Kiers H, Ferreira P, Refshauge K, van Dieën J, Is there a relationship between lumbar proprioception and low back pain? A systematic review with meta-analysis, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2016), doi: 10.1016/ j.apmr.2016.05.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Running head: LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
Is there a relationship between lumbar proprioception and low back pain? A systematic review with meta-analysis
RI PT
Matthew Hoyan Tong1 BAppSc, Seyed Javad Mousavi1 PhD, Henri Kiers2 PhD, Paulo Ferreira1 PhD, Kathryn Refshauge1 PhD, Jaap van Dieën3 PhD
Arthritis and Musculoskeletal Research Group, University of Sydney, Faculty of Health
SC
1
Sciences, Sydney, Australia
Research Group Lifestyle and Health, Faculty of Health Care, University of Applied
M AN U
2
Sciences Utrecht, Faculty of Health Care, Utrecht, Netherlands 3
MOVE Research Institute Amsterdam, Department of Human Movement Sciences, VU
TE D
University Amsterdam, Amsterdam, Netherlands
Preliminary results presented at the World Confederation of Physical Therapy Congress,
EP
Singapore, on 4th May 2015 and the 9th World Congress of the International Society of
AC C
Physical and Rehabilitation Medicine, Berlin, on 20th June 2015
Nil financial support or conflicts of interest to declare - MHT, SJM, HK, PF, KR, JvD Nil other acknowledgements
Systematic review registration number: CRD42015019761
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
Corresponding Author: Matthew Hoyan Tong Address: 42 Raine Road, Revesby, NSW, Australia
RI PT
Business Telephone Number: +61 416 182 820
AC C
EP
TE D
M AN U
SC
Email:
[email protected]
2|Page
Running head: LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
1
Is there a relationship between lumbar proprioception and
2
low back pain? A systematic review with meta-analysis
4
RI PT
3
ABSTRACT
5
SC
6
Objective: To systematically review the relationship between lumbar proprioception and low
8
back pain (LBP)
9
Data Sources: Four electronic databases (PubMed, EMBASE, CINAHL, SPORTDiscus) and
M AN U
7
reference lists of relevant articles were searched from inception to March-April 2014.
11
Study Selection: Studies compared lumbar proprioception in patients with LBP with controls
12
or prospectively evaluated the relationship between proprioception and LBP. Two reviewers
13
independently screened articles and determined inclusion through consensus.
14
Data Extraction: Data extraction and methodological quality assessment were independently
15
performed using standardised checklists.
16
Data Synthesis: Twenty-two studies (1203 participants) were included. Studies measured
17
lumbar proprioception via active or passive joint repositioning sense (JRS) or threshold to
18
detection of passive motion (TTDPM).
19
Data from seventeen studies were pooled for meta-analyses to compare patients with
20
controls. Otherwise, descriptive syntheses were performed. Data were analysed according to
21
measurement method and LBP subgroup.
AC C
EP
TE D
10
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
Active JRS was worse in patients compared to controls when measured in sitting (standard
2
mean difference 0.97, 95% CI 0.31 to 1.64). There were no differences between groups
3
measured via active JRS in standing (standard mean difference 0.41, 95% CI -0.07 to 0.89) or
4
passive JRS in sitting (standard mean difference 0.38, 95% CI -0.83 to 1.58). Patients in the
5
O’Sullivan flexion impairment subgroup had worse proprioception than the total LBP cohort.
6
The TTDPM was significantly worse in patients than controls.
7
One prospective study found no link between lumbar proprioception and LBP.
8
Conclusions: Patients with LBP have impaired lumbar proprioception compared with
9
controls when measured actively in sitting positions (particularly those in the O’Sullivan
10
flexion impairment subgroup) or via TTDPM. Clinicians should consider the relationship
11
between sitting and proprioception in LBP and subgroup patients to guide management.
12
Further studies focusing on subgroups, longitudinal assessment and improving proprioception
13
measurement are needed.
18 19
SC
KEYWORDS
AC C
17
M AN U
TE D
15
EP
14
16
RI PT
1
Rehabilitation, Low back pain, Proprioception
20 21
2|Page
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
1
ABBREVIATIONS
2
5
CE: Constant error
6
DMP: Directional motion perception
7
JRS: Joint repositioning sense
8
LBP: Low back pain
9
NPRS: Numerical pain rating scale
SC
AE: Absolute error
M AN U
4
RI PT
3
ROM: Range of motion
11
TTDPM: Threshold to detection of passive motion
12
VAS: Visual analogue scale
13
VE: Variable error
AC C
EP
TE D
10
3|Page
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
Low back pain (LBP) is a common and challenging medical, social and economic problem
2
throughout the world.1-3 Impairment in lumbar proprioception is a possible mechanism for the
3
development of LBP and is potentially associated with LBP recurrence, particularly if
4
impairments from prior episodes are not resolved. It is thought to decrease the ability to attain
5
and maintain a neutral spinal posture and appropriately coordinate muscle activation. This
6
would compromise spinal control and increase trunk muscle activity and spinal stresses and
7
strains, possibly prolonging LBP and causing further deterioration of prorioception.4-8
RI PT
1
However, the literature examining the relationship between LBP and proprioceptive
M AN U
9
SC
8
impairments appears to be inconsistent. This is most probably due to differences in the
11
methods used to measure proprioception and the characteristics of participants between
12
studies. In light of these issues, the primary aim of this review is to determine whether any
13
differences in lumbar proprioception exist between people with and without LBP by critically
14
evaluating the literature to ascertain its validity and performing meta-analyses. Another aim
15
is to determine whether there are particular subgroups of people with LBP that show a
16
significant impairment in lumbar proprioception, because given the vast range of
17
presentations of LBP encompassing various levels of mechanical impairment and pain
18
intensity, impairments may only be revealed upon the application of subgrouping.8-10
EP
AC C
19
TE D
10
20
Therefore, the specific research questions for this review are:
21
1. Do LBP patients have impaired lumbar proprioception compared with controls?
22
2. Do particular subgroups of LBP have impaired lumbar proprioception compared with
23
other subgroups or with controls?
4|Page
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
1 2
3. Does impaired lumbar proprioception predispose previously healthy participants to the development of LBP?
3
5
RI PT
4
METHODS
SC
6 7
A protocol was written before the systematic review commenced to define the aims and
9
methods. This protocol is available online on the PROSPERO database
10
M AN U
8
(http://www.crd.york.ac.uk/PROSPERO/) under registration number CRD42015019761.
12
15
EP
14
Search Strategy
AC C
13
TE D
11
16
The electronic databases PubMed, EMBASE, CINAHL and SPORTDiscus were searched
17
from their inception to March-April 2014 for relevant articles. The search was restricted to
18
published articles written in English. Search terms are presented in Table 1. A more detailed
19
description of search strategies used can be found in the Supplementary file section.
20
Reference lists of relevant articles were also searched manually for further articles.
21
5|Page
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
1 Two researchers (MT, SJM) independently screened search results for eligible studies by first
3
considering the abstract. If the abstract was potentially eligible, the full text was then
4
obtained and scrutinised before considering inclusion or exclusion of the study. Final
5
decision on inclusion was reached through consensus. Disagreement between researchers was
6
resolved with discussion, or, if that failed, consultation with other reviewers (HK, JvD).
RI PT
2
SC
7 8
Study Selection
M AN U
9 10 11
Studies either comparing proprioception between patients with LBP and controls or
13
prospectively determining the relationship between proprioception and development of LBP
14
were included in the review. Studies were included if they assessed lumbar proprioception in
15
patients with outcome measures of accuracy, precision and error. Studies were excluded if
16
they did not compare patients and controls or had measurement methods that heavily
17
depended on sensory modalities or motor functions other than lumbar proprioception such as
18
lumbar tracking tasks, force generation and standing or sitting on unstable surfaces. Studies
19
were also excluded if they included patients with specific pathology that could directly affect
20
proprioception through mechanisms other than pain, such as neural compromise through disc
21
herniation or spinal stenosis or calcification of connective tissue in ankylosing spondylitis.
22
Results obtained from conference proceedings and theses were excluded.
AC C
EP
TE D
12
23 6|Page
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
1 2
Data Collection
3
RI PT
4 Two researchers (MT, SJM) independently extracted results from included studies.
6
Information regarding study design, participant characteristics (inclusion/exclusion criteria,
7
number, age and gender compositions and pain and disability measures), test protocols,
8
outcomes measured and key findings (mean and SD of test performance and comparison of
9
results between groups) were extracted from the full text of included articles. Only data on
10
proprioception measurements gathered without the addition of extra manipulations intended
11
to influence lumbar proprioception were considered for analysis. If numerical data were not
12
reported in the paper, authors were contacted to determine if they could provide data. Results
13
were categorised and analysed according to which proprioception test was used and the
14
position in which tests were performed, as this has a significant effect on proprioceptive
15
acuity.11
18 19
M AN U
TE D
EP
17
AC C
16
SC
5
Quality Assessment
20 21
All included studies were assessed using a quality assessment checklist. This checklist
22
includes relevant criteria obtained from the Downs and Black Scale12 and the CASP “case-
7|Page
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
1
control” tool13 along with other criteria devised for this review, giving a total of 19 criteria to
2
be assessed in cross-sectional studies and 16 criteria to be assessed in prospective studies.
3 Two researchers (MT, SJM) independently assessed all included studies according to this
5
checklist and disparities were resolved by discussion, or, if that failed, consultation with a
6
third reviewer (JvD). Final decisions were reached through consensus. No studies were
7
excluded based on methodological quality. The checklist is presented in Textbox 1.
SC
RI PT
4
8
10
M AN U
9
Statistical Analysis
11
TE D
12
Methodological quality was compared between studies that found and studies that do not find
14
significant differences in proprioception between patients with LBP and controls using a two
15
tailed Mann-Whitney U test (α=0.05).
AC C
16
EP
13
17
Results appropriate for meta-analysis were combined to a pooled standard mean difference by
18
entering means and standard deviations of errors in proprioception tests reported in individual
19
studies into Review Manager 5.314,a after rounding to one decimal place. Meta-analyses were
20
grouped according to LBP subgroups, given our aims, and according to proprioception
21
measurement methods and testing position. This is because different proprioception
22
measurement methods are poorly correlated with each other15 and testing position has been
8|Page
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
shown to influence proprioceptive acuity.11 When studies reported proprioceptive data in
2
multiple directions within the same testing position, means and standard deviations were
3
pooled to give a single result for inclusion in meta-analysis. The inverse variance weighting
4
method and random effects model were used to pool data. Heterogeneity was quantitatively
5
analysed via the I2 test. If meta-analysis was not possible, the significance of differences in
6
mean error between patients with LBP and controls was examined and a descriptive synthesis
7
of results was performed.
RI PT
1
SC
8
10
M AN U
9
RESULTS
11
14 15
Literature search
EP
13
TE D
12
The search identified 647 studies after removing duplicates. Screening of titles and abstracts
17
left 47 studies. Further scrutiny of full text articles led to the final inclusion of 22 studies in
18
the review. A detailed flowchart of the literature search is presented in Figure 1.
AC C
16
19 20 21
Characteristics of included studies
22 9|Page
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
1 Twenty-one studies (1203 participants) compared patients with LBP with controls using cross
3
sectional designs.16-35 One of these studies recruited patients36 and compared results with
4
matched controls described in a separate study.37 One study (292 participants) examined
5
possible links between lumbar proprioception and LBP development using prospective
6
longitudinal designs.38 Five studies did not adequately report numerical data.16, 19, 28, 29, 33
7
Emails were sent to all lead authors of these studies but only one author provided data for one
8
study.28
SC
RI PT
2
M AN U
9
All studies defined LBP as lumbar pain without a specific established cause. Fourteen studies
11
included patients with LBP of over 3 months duration,16, 17, 19-23, 25, 28-30, 32, 33, 36 four studies
12
included participants with recurrent LBP,16, 19, 24, 27 one study included patients with LBP of
13
over 2 weeks duration26 and five studies did not have criteria regarding LBP duration.18, 27, 31,
14
34, 35
15
vestibular impairment and lower limb symptoms. Some studies also excluded participants
16
who had undergone spinal surgery16, 18, 19, 22, 25, 26, 28-31, 33-36 or motor control training,18, 31
17
participants with psychological impairment21, 32 and participants who were pregnant or
18
breastfeeding.17, 19, 20, 22, 27-30, 32 All studies defined controls as participants without a history of
19
LBP.
EP
All studies excluded participants with systemic disease, neurological impairment,
AC C
20
TE D
10
21
Some studies had additional criteria. One study required patients to have a minimum pain
22
intensity on the Visual Analogue Scale (VAS)/Numerical Pain Rating Scale (NPRS) of
23
3/10,17 while two studies required a minimum VAS of 5/10.20, 29 Three studies required at
24
least a 50% reduction in lumbar range of motion (ROM).20, 28, 29 Two studies required patients 10 | P a g e
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
1
to have LBP-related impairment in physical function.26, 33 Two studies required patients to
2
possess flexion patterns of motor control impairment according to the O’Sullivan
3
classification of LBP.30, 31 Further details regarding demographic data and inclusion and
4
exclusion criteria are presented in Table 2.
RI PT
5 6
Subgrouping of low back pain
SC
7
M AN U
8 9
Two studies sub-grouped patients using the O’Sullivan classification into flexion or extension
11
patterns of motor control impairment.17, 32 Patients with flexion patterns adopt flexed lumbar
12
postures, with pain provocation occurring with flexion and easing with extension.39, 40
13
Patients with extension patterns adopt hyperextended lumbar postures, with pain provocation
14
occurring with extension and easing with flexion.39, 40
TE D
10
EP
15
One study sub-grouped patients using a classification of “mild” and “significant” LBP.27
17
“Significant” LBP was defined as LBP greater than 4/10 on NPRS at its worst, at least one
18
episode of LBP in the past year greater than 1 week duration, greater than 20% disability on
19
the Oswestry Disability Index and the need for pharmacological treatment or reduction of
20
activity in the past year. “Mild” LBP was LBP that did not fit the criteria for “significant”
21
LBP.
AC C
16
22
11 | P a g e
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
1 2
Methods of measuring lumbar proprioception
3
RI PT
4 Twenty-one studies measured lumbar proprioception using joint repositioning sense (JRS)
6
tests (Tables 3-4).16-32, 34-36, 38 Three studies measured lumbar proprioception using threshold
7
to detection of passive motion (TTDPM),25, 33, 38 with two of these studies including
8
directional motion perception (DMP) (Table 5).25, 38 Two studies used both JRS and
9
TTDPM.25, 38
10 11
14
TE D
13
Joint repositioning sense
EP
12
M AN U
SC
5
The JRS test measures how well a participant can replicate a “target position” of the lumbar
16
spine. These are presented through visual feedback, manual guidance or verbal feedback.
17
After presentation of the “target position”, the participant is moved out of the position and
18
asked to replicate it actively (active JRS) or to indicate when they have been moved into the
19
position passively (passive JRS).
AC C
15
20 21
The outcome measure is the difference between the participant’s reproduction of the “target
22
position” and the actual “target position.” There are three possible quantifications of this:
12 | P a g e
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
1
absolute error (AE) is the unsigned difference between positions, constant error (CE) is the
2
signed difference between positions and variable error (VE) is the standard deviation of CE.
3
This review primarily considers AE as it was the most commonly used among included
4
studies.
RI PT
5
Twenty studies used active JRS to measure lumbar proprioception,16-32, 34, 36, 38 three studies
7
used passive JRS25, 35, 38 and two studies used both.25, 38 There was substantial variation in test
8
protocols between studies. A variety of measurement devices were used, including electronic
9
sensors, electro-goniometers, custom lumbar motion devices and tape measures. “Target
M AN U
SC
6
positions” ranged from neutral lumbar spinal postures to targets in pelvic tilting and lumbar
11
flexion, extension, lateral flexion and rotation. “Target positions” were also presented with
12
varying modalities and time limits to memorise positions. However, all studies testing passive
13
JRS used a movement velocity of 1°/second.
14
TE D
10
The number of measurement and practice trials varied widely between included studies. The
16
number of measurement trials performed ranged from 2 to 36 while the number of practice
17
trials performed before starting measurement trials ranged from 0 to 12. One interesting
18
variation was a cross-sectional study which required repositioning within 10% range of the
19
“target position” in 5 consecutive practice trials with visual feedback before starting
20
measurement trials and allowed an unlimited number of practice trials to achieve this.19
21
Although this study found no significant difference in active JRS between patients and
22
controls, some patients required significantly more practice trials (mean 69.4, 95% CI 59.2 to
23
79.0) than controls (mean 41.7, 95% CI 35.0 to 48.5).
AC C
EP
15
24 13 | P a g e
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
1 2
Threshold to detection of passive motion
3
RI PT
4 The TTDPM test measures sensitivity to detection of movement. Starting from a neutral
6
lumbar spine posture, participants undergo passive lumbar movement in custom devices at
7
constant velocity and indicate the earliest point that they sense a positional change. This can
8
be combined with DMP, where participants indicate the direction of the passive movement.
9
Outcome measures are the smallest ROM at which the participant reported movement
M AN U
10
SC
5
(TTDPM) and the direction of movement reported compared to the correct direction (DMP).
11
Three studies used TTDPM to measure lumbar proprioception.25, 33, 38 Two of these studies
13
used DMP alongside TTDPM by only recording TTDPM trials when participants correctly
14
identified the direction of motion.25, 38 The number of measurement trials ranged from 5 to
15
21, with trials performed in both directions within the specified plane of movement. One
16
study did not report the number of practice trials given before measurement trials,33 while
17
two studies gave 2 practice trials in each plane of motion with visual feedback.25, 38 All three
18
studies used similar motion devices in tests of lumbar rotation and one study assessed
19
TTDPM in lateral flexion and flexion/extension.25 Two studies used a movement velocity of
20
0.1°/second and one study used a velocity of 1°/second.
AC C
EP
TE D
12
21 22
14 | P a g e
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
1
Methodological quality of included studies
2 3 Methodological quality of all studies is shown in Table 6. Among the cross-sectional trials
5
the average quality score was 14.3 (lowest 11, highest 17) out of a maximum 19. The one
6
prospective study scored 13 out of 16.
RI PT
4
SC
7
Certain criteria in the quality checklist were poorly addressed. Only one study described the
9
treatment history of patients with LBP,25 five studies justified their sample size as
M AN U
8
appropriate17, 26, 27, 32, 34 and six studies referenced or gathered data reporting their outcome
11
measures as having high reliability.16, 21, 22, 26, 33, 34 Only six studies included all participant
12
demographics and characteristics in appropriate detail,17, 19, 24, 25, 27, 38 with the most common
13
characteristic not reported being average LBP duration. Only nine studies provided definitive
14
evidence that patients and controls were recruited from the same population.17, 19, 20, 27, 30, 31, 33,
15
34, 38
EP
TE D
10
16
Many criteria were well addressed. All studies adequately stated their objective(s), had
18
appropriate designs, described inclusion and exclusion criteria in appropriate detail, recruited
19
appropriate controls, described their outcome measures, used objective measurement
20
instruments and reported results obtained through appropriate statistical analyses. Most
21
studies recruited clinically representative patients,16-19, 21, 22, 26-33, 35 reported effect sizes16-18, 20-
22
36, 38
23
confounders in their results analysis and interpretation.16-20, 22, 24-26, 28-31, 33-36, 38
AC C
17
and the random variability of their data16-18, 20-32, 34-36, 38 and recognised and addressed
15 | P a g e
LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW
ACCEPTED MANUSCRIPT
1 There was no difference in quality scores between the twelve cross-sectional studies that
3
found at least one significant difference in proprioception between patients and controls
4
(median 14)18, 20-22, 25, 26, 29-33, 35 and the nine cross-sectional studies that found no significant
5
differences in proprioception (median 14)16, 17, 19, 23, 24, 27, 28, 34, 36 (Mann-Whitney U 52.5,
6
p=0.92).
RI PT
2
SC
7 8
10
Comparisons of lumbar proprioception between patients with LBP
M AN U
9
and controls
11
14 15
Patients compared with controls
EP
13
TE D
12
Meta-analysis of 8 studies measuring AE during active JRS in sitting positions revealed
17
significantly impaired proprioception in patients with LBP compared with controls (pooled
18
standard mean difference 0.97, 95% CI 0.31 to 1.64, I2 90%) (Figure 2). Meta-analysis of 7
19
studies measuring AE during active JRS in standing positions revealed no significant
20
difference in proprioception between patients and controls (pooled standard mean difference
21
0.41, 95% CI -0.07 to 0.89, I2 79%) (Figure 3). One study measured active JRS in four point
22
kneeling and found a 2.4° higher mean AE in patients (mean AE 8.1°, SD 14.4) compared
23
with controls (mean AE 5.7°, SD 8.1) (p6 months
TE D
CS
LBP >12 weeks of VAS >3/10 experienced most days of week
28 LBP
No peripheral pain, neurological impairment, lumbar spine surgery
28
EP
Asell
No pelvic or abdominal pain in last 12 months
AC C
1
M AN U
SC
pants
Not pregnant or 6 months
(2005)19
No neurological impairment, severe scoliosis, previous spinal surgery,
15
systemic disease
Controls
M AN U
4
SC
Not taking pain medication
RI PT
3
16 LBP
40.9 (11.4), 38.2 (10.7), 11M, 5F
9M, 6F
15 LBP
40.1 (6.1)
38.5 (5.9)
15
Gender not
Gender not
Controls
reported
reported
(2011)20
CS
LBP of VAS >5/10, lumbar ROM 3 months duration
EP
Georgy
AC C
5
TE D
Not currently pregnant or breastfeeding
No inner ear pathology, neurological impairment, systemic disease Not currently pregnant or breastfeeding
ACCEPTED MANUSCRIPT
(1998)21
7
Hidalgo
CS
(2013)22
LBP with or without leg pain as far as knee > 1 year duration No neurological impairment, mental disorders, further medical
12
problems
Controls
LBP without radiation into leg >6 months
28
lumbar spine surgery
Controls
TE D
LBP >2 years
EP
(2011)23
CS
AC C
Kara
10 LBP
No vestibular disease, systemic disease, neurological impairment,
Not pregnant 8
20 LBP,
RI PT
CS
SC
Gill
M AN U
6
18 LBP 18 Controls
43.3 (12.4), 32.9 (8.7), 7M, 13F
7M, 13F
33.8 (7.5),
27.7 (9.7),
5M, 5F
14M, 14F
48.2 (9.7),
44.5 (3.9),
8M, 10F
9M, 9F
ACCEPTED MANUSCRIPT
9
Koumantakis CS
Recurrent LBP (at least 2 episodes in past year) with pain duration less than half the days in past year >6 weeks after onset
(2002)24
RI PT
Still working No neurological impairment
group (CS
LBP >3 months
SC
(1999)36
Single
30M,32F
8M, 10F
29 (5),
23, 5M, 5F*
Controls
20 LBP
surgery
Controls
TE D
LBP >3 months
24 LBP 24
knee
Controls
EP
No history of spinal surgery, neurological impairment, pain below
AC C
(2010)25
CS
18
10
analysis) 11 Lee
38.2 (10.7) 24.6 (4)
No neurological impairment, previous back, abdominal or chest
M AN U
10 Lam
62 LBP
11M, 9F
42.6
42.4 (9.0),
(13.7),
14M, 10F
11M, 13F
ACCEPTED MANUSCRIPT
limb symptoms, untreated systemic disease
Controls
Chronic or recurrent LBP Not pregnant or 2 weeks with mild-moderate impairment of physical function
EP
CS
AC C
12 Lin
31.8 (9.9),
34.4 (10.5),
10M, 10F
9M, 11F
134 LBP Mild: 22.0 (Mild: 81 Significant: 53) 39 Controls
(4.2) Significant: 23.9 (5.1)
21.7 (3.5)
ACCEPTED MANUSCRIPT
CS
(2000) (1)28
LBP >3 months, lumbar ROM 5/10,
TE D
No severe scoliosis, neurological impairment, lower limb problems Not currently pregnant or lactating
EP
(2000) (2)29
CS
AC C
15 Newcomer
SC
Not currently pregnant or lactating
RI PT
14 Newcomer
Controls
20 LBP 20 Controls
39.3
39.1 (11.3),
(11.4),
7M, 13F
8M, 12F
44.2
39.8 (12.7),
(10.6),
9M, 11F
9M, 11F
ACCEPTED MANUSCRIPT
16 O’Sullivan CS (2003)31
LBP >3 months in subgroup of flexion pattern lumbar segmental instability (O’Sullivan classification)
15
trunk
M AN U
LBP >3 months in subgroup of flexion pattern of motor control impairment (O’Sullivan classification) No previous back surgery
TE D
No neurological symptoms
EP
Not pregnant or 12 weeks with clinical diagnosis of flexion or active extension pattern of motor control impairment (O’Sullivan classification)
(2012)32
No dominant maladaptive psychosocial behaviour
57 LBP
Still working
49
M AN U
LBP >3 months with impairment of physical function
EP
No recent major surgery
TE D
No neurological impairment, severe systemic disease
AC C
(2010)33
SC
No previous spinal surgery, neurological impairment CS
35
35 (10.8),
36.0 (10.3),
31M, 59F
13M, 22F
41.4 (7.4),
38.9 (9.0),
27M, 30F
28M, 21F
Controls
Not pregnant or breastfeeding
19 Taimela
90 LBP
RI PT
18 Sheeran
Controls
ACCEPTED MANUSCRIPT
20 Tsai
CS
16 LBP
No previous back surgery
16
RI PT
(2010)34
LBP within past 2 years
(2010)35
CS
LBP > 3 months with no radiation below knee level
disease that can affect proprioception
Controls
TE D EP
AC C
(2007)38
19 LBP 20
Prospective Not reported
47.9 (8.3),
all M
all M
All M
All M
N/A
19.5 (1.6),
Controls
No neurological impairment, current lower limb problems, systemic
No previous back surgery 22 Silfies
M AN U
21 Yilmaz
SC
No neurological impairment, current lower limb symptoms
48.6 (7.4),
292 initially without LBP
144M, 148F
AC C
EP
TE D
M AN U
SC
* The age and gender matched healthy group was obtained from a separate study37
RI PT
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
Table 3 – Measurement protocols of included studies measuring proprioception via active joint repositioning sense. Movement
(year)
device
position
performed
Asell
Fastrak
Sitting
Pelvic
Target position
1/3 LSp Ext ROM
2
TE D
Sitting
LSp Flex/Ext Neutral
EP
(2013)17
Fastrak
AC C
Astfalck
Researcher manual guidance, 2 second
backward tilt
2
Practice
presentation method
forward/
(2006)16
Target position
RI PT
Measurement Start
SC
1
Author
M AN U
1
hold
Number of trials
3 tries
10
verbal instructions 3 tries prerecorded instructions
Researcher manual guidance, 5 second hold
2 tries
3
ACCEPTED MANUSCRIPT
Brumagne
Electro-
(2000)18
goniometer
Sitting
Pelvic
Variation around
Researcher verbal
forward/
Neutral
instruction, 5 second
backward tilt
Descarreaux “Rehabilitation Neutral device”
standing
LSP
15°, 30°, 60° LSp
Flex/Ext
Flex, 15° LSp Ext
Visual feedback via
(2011)20
dynamometer
Neutral
EP
Isokinetic
starting
Visual
10
computer screen data feedback and within 10% of target 5 consecutive
TE D 1
Georgy
LSp Flex/Ext 30° LSp Flex
AC C
5
5
hold
M AN U
(2005)19
Nil
SC
4
RI PT
3
times before testing Apparatus manual guidance, 10 second hold
3 tries
3
ACCEPTED MANUSCRIPT
(1998)21
goniometer
Hidalgo
3D tracking
(2013)22
system
Standing
LSp Flex/Ext 20° LSp Flex
Visual feedback via
Visual
10
computer screen data feedback
RI PT
Electro-
LSp Flex/Ext 30° LSp Flex
Neutral
Electronic audio-
10 tries Nil
5
SC
7
Gill
signal feedback, 3
LSp sitting
M AN U
6
second hold
Kara
Tape
(2011)23
measure (Schober’s
LSp
5cm LSp Flex, 10cm
Researcher verbal
Visual
3 (1 each
Flex/Ext, LF
LF (L & R)
feedback, 5 second
feedback
position)
AC C
EP
test)
Standing
TE D
8
1
hold
Each position held for 30s before testing
ACCEPTED MANUSCRIPT
(2002)24
Standing
goniometer
LSp
20° LSp Flex, 15°
Flex/Ext, LF, Rot (L & R), 15° LF Rot
TE D
Custom
Seated,
LSp rot, LF,
lumbar
Supine,
Flex/Ext
motion device
Side-lying respectively
respectively
EP
(2010)25
LSp Flex/Ext Neutral
sitting
(1999)36
11 Lee
Neutral
M AN U
Fastrak
AC C
10 Lam
(L & R)
Neutral
Visual feedback,
Standardised 15 (3 each
performance
training,
RI PT
Koumantakis Electro-
feedback from
number of
computer
tries not
SC
9
Researcher manual
position)
reported 5 tries
3
Apparatus manual
2 tries with
21 (4 trials
guidance
each plane
each
of motion
direction
guidance
LF & Rot, 5 trials Flex/Ext positions)
ACCEPTED MANUSCRIPT
(2010)26
Ribbon-
Standing
LSp Flex/Ext Variation around 35-
mounted
45° LSp Flex
instruction, 5 second
sensors Sitting
LSp Flex/Ext Neutral
Researcher manual
3
reported
Nil
5
Researcher verbal
Not
18 (3 each
Flex/Ext, LF, LF (L & R), Rot (L
instruction, 2 second
reported
position)
Rot
hold
M AN U
Fastrak
Not
hold
SC
fibre-optic
13 Mitchell
Researcher verbal
RI PT
12 Lin
guidance, 5 second
(2009)27
hold
50% LSp Flex, Ext,
TE D
(1)28
LSp
& R) ROM
EP
(2000)
Standing
AC C
14 Newcomer Fastrak
ACCEPTED MANUSCRIPT
(2000)
LSp
30, 50 & 90% LSp
Researcher verbal
Not
12 (1 each
Flex/Ext, LF
Flex, Ext, LF (L &
instruction, 2 second
reported
position)
R) ROM
hold
Nil
5
1 try
3
Researcher manual
3 tries each
8 (4 each
guidance, 5 second
in standing
position)
hold
and sitting
(2)29 16 O’Sullivan Fastrak
Sitting
LSp Flex/Ext Neutral
RI PT
Standing
Researcher manual
SC
15 Newcomer Fastrak
guidance, 5 second
M AN U
(2003)31
hold
17 O’Sullivan Strain
LSp Flex/Ext Neutral
monitor
(2012)32
3D
Sitting &
kinematic
Standing
motion analysis system
LSp Flex/Ext Neutral
AC C
18 Sheeran
Researcher manual guidance, 5 second
TE D
gauge
EP
(2013)30
Sitting
hold
ACCEPTED MANUSCRIPT
Sitting
LSp Rot
Neutral
Apparatus manual
2 tries each
10 (5 each
motion device
guidance
direction
position)
80% LSp Flex, Ext,
Electronic audio-
tracking device
Ext, LF, Rot
LF (L & R), Rot (L
signal feedback, 4
& R) ROM
second hold
TE D
LSp Flex,
EP
(2010)34
Electromagnetic Standing
AC C
20 Tsai
M AN U
SC
(2007)38
Custom lumbar
RI PT
19 Silfies
with verbal feedback Nil
36 (6 each position)
ACCEPTED MANUSCRIPT
Table 4 – Measurement protocols of included studies measuring proprioception via passive joint repositioning sense Measurement Start
Movement
Movement
(year)
device
performed
velocity
position
Target position
Target position
RI PT
Author
Practice
presentation
Number of trials
Lee
Custom
Seated,
LSp rot,
(2010)25
lumbar
Supine,
LF,
motion
respectively
Flex/Ext respectively
Apparatus
2 tries with
21 (4 trials
manual
each plane
each
guidance
of motion
direction LF & Rot, 5 trials
Silfies
Custom
(2007)38
lumbar motion device
Sitting
LSp Rot
AC C
2
EP
TE D
device
Side-lying
1.0°/second Neutral
M AN U
1
SC
method
1.0°/second Neutral
Flex/Ext positions) Apparatus
2 tries each
10 (5 each
manual
direction
direction)
guidance
with verbal feedback
ACCEPTED MANUSCRIPT
1.0°/second 60° LSp Flex
Apparatus manual
RI PT
Flex/Ext
guidance
SC
dynamometer
LSp
M AN U
(2010)35
Sitting
TE D
Isokinetic
EP
Yilmaz
AC C
3
Nil
2
ACCEPTED MANUSCRIPT
Table 5 – Measurement protocols of included studies measuring proprioception via threshold to detection of passive motion and directional
(year)
test
device
performed
Lee
TTDPM,
Custom lumbar Seated,
LSp rot, LF,
(2010)25
DMP (trials
motion device
Supine, Side-lying
if direction
respectively
correctly)
EP
reported
Movement
Practice
velocity 0.1°/second
Number of trials
2 tries with
21 (4 trials
Flex/Ext
each plane of
each
respectively
motion
direction of
TE D
only recorded
Movement
SC
Start position
M AN U
Proprioception Measurement
AC C
1
Author
RI PT
motion perception. All participants initially moved from neutral lumbar spinal posture
LF & Rot, 5 trials Flex/Ext positions)
ACCEPTED MANUSCRIPT
Silfies
TTDPM,
(2007)38
DMP (trials
Custom lumbar Sitting
LSp Rot
motion device
only recorded
correctly) Custom lumbar Sitting
LSp Rot
EP
TE D
motion device
AC C
(1999)33
TTDPM
M AN U
reported
Taimela
2 tries each
10 (5 each
direction with
direction)
verbal feedback
SC
if DMP
3
0.1°/second
RI PT
2
1°/second
Standardised training period, but number of tries not reported
5
ACCEPTED MANUSCRIPT
Table 6 – Quality assessment of included studies Brumag ne et al 200018
Descarre aux et al 200519
Georgy 201120
Is a research question describing the objective of the study clearly posed? Is the design of the study appropriate for the research question? Are the inclusion and exclusion criteria clearly described? Is there sufficient information about participant characteristics? Is the treatment history of the LBP patients described? Was there an appropriate sample size of LBP patients and controls OR of prospective participants? Were LBP patients clinically representative? Were controls representative of a non-pathological group? Were the LBP patients and controls recruited from the same population? Were controls matched with LBP patients in important characteristics? Are the methods for assessment of outcome measures clearly described? Were the outcome measures reliable? Were the outcome measures valid? Were any confounding effects on outcome measures considered in analysis/interpretation of results? Was there blinding/attempted blinding of assessors to whether participants were LBP patients or controls OR was an objective instrument that did not allow the assessor to influence performance/interpretation used? Were appropriate statistical tests used to assess differences between groups? Are the main findings of the study clearly described? Does the study provide estimates of effect size for the main outcomes? Does the study provide estimates of the random variability in the data for the main outcomes?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
N
Y
N N
N Y
N N
N N
Y Y
Y Y
Y Y
N
Y
N
Y
Y
Y
Score (/19 unless otherwise specified)
Hidalgo et al 201322
Kara et al 201123
Kouman takis et al 200224
Lam et al 199936
Lee et al 201025
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
Y
N
Y
N
N N
N N
N N
N N
N N
N N
Y N
N Y
Y Y
N Y
Y Y
Y Y
N Y
N Y
N Y
N Y
Y Y
Y
Y
N
N
N
N
N
N
N
Y
Y
N
Y
Y
N
N
Y
Y
M AN U
TE D
Lin & Sun 200626
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N Y Y
N Y Y
N Y Y
N Y Y
Y Y N
Y Y Y
N Y N
N Y Y
N Y Y
N Y Y
Y Y Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y Y
Y Y
Y Y
Y N
Y Y
Y Y
Y Y
Y Y
Y Y
Y Y
Y Y
Y Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
15
17
14
14
14
13
15
12
13
11
15
16
Y Y Y Y
EP
Y
Gill & Callagha n 199821
RI PT
Astfalck et al 201317
SC
Asell et al 200616
AC C
Criterion
ACCEPTED MANUSCRIPT
Newcom er et al 2000 (1)28
Newcom er et al 2000 (2)29
O’Sulliv an et al 200331
O’Sulliv an et al 201330
Sheeran et al 201232
Silfies et al 200738
Taimela et al 199933
Tsai et al 201034
Is a research question describing the objective of the study clearly posed? Is the design of the study appropriate for the research question? Are the inclusion and exclusion criteria clearly described? Is there sufficient information about participant characteristics? Is the treatment history of the LBP patients described? Was there an appropriate sample size of LBP patients and controls OR of prospective participants? Were LBP patients clinically representative? Were controls representative of a non-pathological group? Were the LBP patients and controls recruited from the same population? Were controls matched with LBP patients in important characteristics? Are the methods for assessment of outcome measures clearly described? Were the outcome measures reliable? Were the outcome measures valid? Were any confounding effects on outcome measures considered in analysis/interpretation of results? Was there blinding/attempted blinding of assessors to whether participants were LBP patients or controls OR was an objective instrument that did not allow the assessor to influence performance/interpretation used? Were appropriate statistical tests used to assess differences between groups? Are the main findings of the study clearly described? Does the study provide estimates of effect size for the main outcomes? Does the study provide estimates of the random variability in the data for the main outcomes?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
Y
N
N
N
N Y
N N
N N
N N
N N
N Y
N N
N N
N Y
N N
Y Y
Y Y
Y Y
Y Y
Y Y
Y Y
N/A N/A
Y Y
N Y
Y Y
Y
N
N
Y
Y
N
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
N/A
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N Y Y
N Y Y
N Y Y
N Y Y
N Y N
N Y Y
Y Y Y
Y Y Y
N Y Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y Y
Y Y
Y Y
Y Y
Y Y
Y Y
Y Y
Y Y
Y Y
Y Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Score (/19 unless otherwise specified)
16
14
14
15
15
14
13/16
15
16
14
SC
M AN U
TE D
AC C
Y
EP
N Y N
RI PT
Mitchell et al 200927
Criterion
Yilmaz et al 201035
ACCEPTED MANUSCRIPT
RI PT
Records identified through database searching (n = 927)
Additional records identified through other sources (n = 0)
SC
Identification
PRISMA 2009 Flow Diagram
M AN U
Records screened (n = 647)
EP
TE D
Full-text articles assessed for eligibility (n = 48)
AC C
Included
Eligibility
Screening
Records after duplicates removed (n = 647)
Studies included in qualitative synthesis (n = 22)
Studies included in quantitative synthesis (meta-analysis) (n = 17)
Records excluded (n = 599)
Full-text articles excluded (n = 25) Conference proceedings and theses (n = 7) Patients with LBP related to specific pathology (n = 6) No analysis between LBP and control groups (n = 5) No analysis without addition of extra treatments (n = 3) Tests not true measure of proprioception (n=2) Prospective study did not start with healthy participants (n=1)
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and MetaAnalyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097
For more information, visit www.prisma-statement.org.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT Table 2 – Quality assessment checklist used to evaluate quality of included studies
RI PT
Criterion 1. Is a research question describing objective of study clearly posed?
SC
2. Is the design of the study appropriate for the research question?
M AN U
3. Are the inclusion and exclusion criteria clearly described?
4. Is there sufficient information about participant characteristics? 5. Is the treatment history of the LBP patients described?
participants?
TE D
6. Was there an appropriate sample size of LBP patients and controls OR of prospective
EP
7. Were LBP patients clinically representative? 8. Were controls representative of a non-pathological group?
AC C
9. Were the LBP patients and controls recruited from the same population? 10. Were controls matched with LBP patients in important characteristics 11. Are the methods for assessment of outcome measures clearly described? 12. Were the outcome measures reliable? 13. Were the outcome measures valid?
ACCEPTED MANUSCRIPT
14. Were any confounding effects on outcome measures considered in analysis/interpretation of results
RI PT
15. Was there blinding/attempted blinding of assessors to whether participants were LBP patients or controls OR was an objective instrument that did not allow the assessor to influence performance/interpretation used?
M AN U
17. Are the main findings of the study clearly described?
SC
16. Were appropriate statistical tests used to assess differences between the groups?
18. Does the study provide estimates of the random variability in the data for the main outcomes (confidence intervals, standard error, standard deviation, interquartile range)?
TE D
19. Does the study provide estimates of effect size for the main outcomes (group means,
AC C
EP
percentage differences)?
ACCEPTED MANUSCRIPT
SUPPLEMENTARY FILES
RI PT
Supplementary file 1 – Full search strategy used in PubMed on 20/03/2014
SC
Low back pain (42 109 hits)
"Back Pain"[Mesh] OR "back pain"[tiab] OR "back pain"[ot] OR "lumbar pain"[tiab] OR
M AN U
"lumbar pain"[ot] OR "back trouble"[tiab] OR "back trouble"[ot] OR "lumbar trouble"[tiab] OR "lumbar trouble"[ot] OR "back dysfunction"[tiab] OR "back dysfunction"[ot] OR "lumbar dysfunction"[tiab] OR "lumbar dysfunction"[ot] OR "back complaints"[tiab] OR "back complaints"[ot] OR "lumbar complaints"[tiab] OR "lumbar complaints"[ot] OR "back
TE D
symptoms"[tiab] OR "back symptoms"[ot] OR "lumbar symptoms"[tiab] OR "lumbar symptoms"[ot] OR "back ache"[tiab] OR "back ache"[ot] OR "lumbar ache"[tiab] OR
EP
"lumbar ache"[ot]
AC C
Proprioception (40 745 hits)
“Proprioception"[Mesh] OR Propriocep*[tiab] OR Propriocep*[ot] OR "movement sense"[tiab] OR "movement sense"[ot] OR kinesthe*[tiab] OR kinesthe*[ot] OR mechanoreceptors[tiab] OR mechanoreceptors[ot] OR "muscle spindle"[tiab] OR "muscle spindle"[ot] OR "muscle spindles"[tiab] OR "muscle spindles"[ot] OR "motion threshold"[tiab] OR "motion threshold"[ot] OR "movement threshold"[tiab] OR "movement threshold"[ot] OR "repositioning"[tiab] OR "repositioning"[ot] OR "position sense"[tiab] OR
ACCEPTED MANUSCRIPT "position sense"[ot] OR "motion perception"[tiab] OR "motion perception"[ot] OR "movement detection"[tiab] OR "movement detection"[ot]
AC C
EP
TE D
M AN U
SC
RI PT
(low back pain) AND (proprioception) = 404 hits
ACCEPTED MANUSCRIPT Supplementary file 2 – Full search strategy used in EMBASE on 08/04/2014
Low back pain (63 211 hits)
RI PT
‘backache’/exp OR ‘back pain’:ti:ab OR ‘lumbar pain’:ti:ab OR ‘back trouble’:ti:ab OR ‘lumbar trouble’:ti:ab OR ‘back dysfunction’:ti:ab OR ‘lumbar dysfunction’:ti:ab OR ‘back complaints’:ti:ab OR ‘lumbar complaints’:ti:ab OR ‘back symptoms’:ti:ab OR ‘lumbar
AND [embase]/lim
Proprioception (24 041 hits)
M AN U
SC
symptoms’:ti:ab OR ‘back ache’:ti:ab OR ‘backache’:ti:ab OR ‘lumbar ache’:ti:ab
TE D
'proprioception'/exp OR propriocep*:ti:ab OR ‘movement sense’:ti:ab OR kinesthe*:ti:ab OR mechanoreceptors:ti:ab OR ‘muscle spindle’:ti:ab OR ‘muscle spindles’:ti:ab OR ‘motion
EP
threshold’:ti:ab OR ‘movement threshold’:ti:ab OR ‘repositioning’:ti:ab OR ‘position
AC C
sense’:ti:ab OR ‘motion perception’:ti:ab OR ‘movement detection’:ti:ab
AND [embase]/lim
(low back pain) AND (proprioception) = 305 hits
ACCEPTED MANUSCRIPT Supplementary file 3 – Full search strategy used in CINAHL on 20/03/2014
Query
Results
S28
S26 AND S27
S27
S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR
RI PT
#
132
S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10
21,479
TI "motion detection" OR AB "motion detection"
34
S24
TI "motion perception" OR AB "motion perception"
61
S23
TI "position sens*" OR AB "position sens*"
384
S22
TI repositioning OR AB repositioning
988
S21
TI "movement threshold" OR AB "movement threshold"
1
TI "motion threshold" OR AB "motion threshold"
4
S19
TI "muscle spindle*" OR AB "muscle spindle*"
105
S18
TI mechanoreceptors OR AB mechanoreceptors
149
AC C
S20
EP
S25
TE D
OR S11 OR S12 OR S13
M AN U
S26
SC
S22 OR S23 OR S24 OR S25
4,360
ACCEPTED MANUSCRIPT TI kinesthe* OR AB kinesthe*
285
S16
TI "movement sense" OR AB "movement sense"
12
S15
TI Propriocep* OR AB Propriocep*
1,647
S14
(MH "Proprioception+")
S13
TI "lumbar ache" OR AB "lumbar ache"
S12
TI "lumbar symptoms" OR AB "lumbar symptoms"
S11
TI "lumbar complaints" OR AB "lumbar complaints"
5
S10
TI "lumbar dysfunction" OR AB "lumbar dysfunction"
8
S9
TI "lumbar trouble" OR AB "lumbar trouble"
1
S8
TI "lumbar pain" OR AB "lumbar pain"
183
S7
TI "back ache" OR AB "back ache"
10
S6
TI "back symptoms" OR AB "back symptoms"
90
TI "back complaints" OR AB "back complaints"
46
S4
TI "back dysfunction" OR AB "back dysfunction"
22
S3
TI "back trouble" OR AB "back trouble"
31
2,280
EP
TE D
M AN U
SC
1
AC C
S5
RI PT
S17
10
ACCEPTED MANUSCRIPT TI "back pain" OR AB "back pain"
13,424
S1
(MH "Back Pain+")
18,744
AC C
EP
TE D
M AN U
SC
RI PT
S2
ACCEPTED MANUSCRIPT Supplementary file 4 – Full search strategy used in SPORTDiscus on 20/03/2014
Query
Results
S28
S26 AND S27
S27
S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21
RI PT
#
86
S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR 6,396 S11 OR S12 OR S24
S25
M AN U
S26
SC
OR S22 OR S23 OR S25
5,952
DE "PROPRIOCEPTION" OR DE "EQUILIBRIUM (Physiology)" OR
3,679
TE D
DE "MUSCULAR sense" OR DE "PROPRIOCEPTORS"
DE "BACKACHE" OR DE "SACROCOXALGIA"
4,503
S23
TI "motion detection" OR AB "motion detection"
14
S22
TI "motion perception" OR AB "motion perception"
AC C
S21
EP
S24
38
TI "position sens*" OR AB "position sens*"
396
TI repositioning OR AB repositioning
360
S19
TI "movement threshold" OR AB "movement threshold"
2
S18
TI "motion threshold" OR AB "motion threshold"
1
S20
TI "muscle spindle*" OR AB "muscle spindle*"
137
S16
TI mechanoreceptors OR AB mechanoreceptors
188
S15
TI kinesthe* OR AB kinesthe*
719
S14
TI "movement sense" OR AB "movement sense"
S13
TI Propriocep* OR AB Propriocep*
S12
TI "lumbar ache" OR AB "lumbar ache"
S11
TI "lumbar symptoms" OR AB "lumbar symptoms"
3
S10
TI "lumbar complaints" OR AB "lumbar complaints"
2
S9
TI "lumbar dysfunction" OR AB "lumbar dysfunction"
2
S8
TI "lumbar trouble" OR AB "lumbar trouble"
0
S7
TI "lumbar pain" OR AB "lumbar pain"
68
S6
TI "back ache" OR AB "back ache"
13
TI "back symptoms" OR AB "back symptoms"
36
S4
TI "back complaints" OR AB "back complaints"
24
S3
TI "back dysfunction" OR AB "back dysfunction"
21
11
TE D
M AN U
SC
2,223
AC C
S5
RI PT
S17
EP
ACCEPTED MANUSCRIPT
0
ACCEPTED MANUSCRIPT TI "back trouble" OR AB "back trouble"
29
S1
TI "back pain" OR AB "back pain"
5,274
AC C
EP
TE D
M AN U
SC
RI PT
S2