Is there a relationship between lumbar proprioception and low back ...

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

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Is there a relationship between lumbar proprioception and low back pain? A systematic review with meta-analysis

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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

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Sciences, Sydney, Australia

Research Group Lifestyle and Health, Faculty of Health Care, University of Applied

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Sciences Utrecht, Faculty of Health Care, Utrecht, Netherlands 3

MOVE Research Institute Amsterdam, Department of Human Movement Sciences, VU

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University Amsterdam, Amsterdam, Netherlands

Preliminary results presented at the World Confederation of Physical Therapy Congress,

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Singapore, on 4th May 2015 and the 9th World Congress of the International Society of

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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

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Corresponding Author: Matthew Hoyan Tong Address: 42 Raine Road, Revesby, NSW, Australia

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Business Telephone Number: +61 416 182 820

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Email: [email protected]

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Running head: LUMBAR PROPRIOCEPTION AND LOW BACK PAIN REVIEW

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Is there a relationship between lumbar proprioception and

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low back pain? A systematic review with meta-analysis

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ABSTRACT

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Objective: To systematically review the relationship between lumbar proprioception and low

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back pain (LBP)

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Data Sources: Four electronic databases (PubMed, EMBASE, CINAHL, SPORTDiscus) and

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reference lists of relevant articles were searched from inception to March-April 2014.

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Study Selection: Studies compared lumbar proprioception in patients with LBP with controls

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or prospectively evaluated the relationship between proprioception and LBP. Two reviewers

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independently screened articles and determined inclusion through consensus.

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Data Extraction: Data extraction and methodological quality assessment were independently

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performed using standardised checklists.

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Data Synthesis: Twenty-two studies (1203 participants) were included. Studies measured

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lumbar proprioception via active or passive joint repositioning sense (JRS) or threshold to

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detection of passive motion (TTDPM).

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Data from seventeen studies were pooled for meta-analyses to compare patients with

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controls. Otherwise, descriptive syntheses were performed. Data were analysed according to

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measurement method and LBP subgroup.

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Active JRS was worse in patients compared to controls when measured in sitting (standard

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mean difference 0.97, 95% CI 0.31 to 1.64). There were no differences between groups

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measured via active JRS in standing (standard mean difference 0.41, 95% CI -0.07 to 0.89) or

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passive JRS in sitting (standard mean difference 0.38, 95% CI -0.83 to 1.58). Patients in the

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O’Sullivan flexion impairment subgroup had worse proprioception than the total LBP cohort.

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The TTDPM was significantly worse in patients than controls.

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One prospective study found no link between lumbar proprioception and LBP.

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Conclusions: Patients with LBP have impaired lumbar proprioception compared with

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controls when measured actively in sitting positions (particularly those in the O’Sullivan

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flexion impairment subgroup) or via TTDPM. Clinicians should consider the relationship

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between sitting and proprioception in LBP and subgroup patients to guide management.

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Further studies focusing on subgroups, longitudinal assessment and improving proprioception

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measurement are needed.

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KEYWORDS

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Rehabilitation, Low back pain, Proprioception

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ABBREVIATIONS

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CE: Constant error

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DMP: Directional motion perception

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JRS: Joint repositioning sense

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LBP: Low back pain

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NPRS: Numerical pain rating scale

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AE: Absolute error

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ROM: Range of motion

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TTDPM: Threshold to detection of passive motion

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VAS: Visual analogue scale

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VE: Variable error

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Low back pain (LBP) is a common and challenging medical, social and economic problem

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throughout the world.1-3 Impairment in lumbar proprioception is a possible mechanism for the

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development of LBP and is potentially associated with LBP recurrence, particularly if

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impairments from prior episodes are not resolved. It is thought to decrease the ability to attain

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and maintain a neutral spinal posture and appropriately coordinate muscle activation. This

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would compromise spinal control and increase trunk muscle activity and spinal stresses and

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strains, possibly prolonging LBP and causing further deterioration of prorioception.4-8

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However, the literature examining the relationship between LBP and proprioceptive

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impairments appears to be inconsistent. This is most probably due to differences in the

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methods used to measure proprioception and the characteristics of participants between

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studies. In light of these issues, the primary aim of this review is to determine whether any

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differences in lumbar proprioception exist between people with and without LBP by critically

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evaluating the literature to ascertain its validity and performing meta-analyses. Another aim

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is to determine whether there are particular subgroups of people with LBP that show a

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significant impairment in lumbar proprioception, because given the vast range of

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presentations of LBP encompassing various levels of mechanical impairment and pain

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intensity, impairments may only be revealed upon the application of subgrouping.8-10

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Therefore, the specific research questions for this review are:

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1. Do LBP patients have impaired lumbar proprioception compared with controls?

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2. Do particular subgroups of LBP have impaired lumbar proprioception compared with

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other subgroups or with controls?

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3. Does impaired lumbar proprioception predispose previously healthy participants to the development of LBP?

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METHODS

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A protocol was written before the systematic review commenced to define the aims and

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methods. This protocol is available online on the PROSPERO database

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(http://www.crd.york.ac.uk/PROSPERO/) under registration number CRD42015019761.

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Search Strategy

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The electronic databases PubMed, EMBASE, CINAHL and SPORTDiscus were searched

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from their inception to March-April 2014 for relevant articles. The search was restricted to

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published articles written in English. Search terms are presented in Table 1. A more detailed

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description of search strategies used can be found in the Supplementary file section.

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Reference lists of relevant articles were also searched manually for further articles.

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1 Two researchers (MT, SJM) independently screened search results for eligible studies by first

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considering the abstract. If the abstract was potentially eligible, the full text was then

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obtained and scrutinised before considering inclusion or exclusion of the study. Final

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decision on inclusion was reached through consensus. Disagreement between researchers was

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resolved with discussion, or, if that failed, consultation with other reviewers (HK, JvD).

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Study Selection

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Studies either comparing proprioception between patients with LBP and controls or

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prospectively determining the relationship between proprioception and development of LBP

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were included in the review. Studies were included if they assessed lumbar proprioception in

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patients with outcome measures of accuracy, precision and error. Studies were excluded if

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they did not compare patients and controls or had measurement methods that heavily

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depended on sensory modalities or motor functions other than lumbar proprioception such as

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lumbar tracking tasks, force generation and standing or sitting on unstable surfaces. Studies

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were also excluded if they included patients with specific pathology that could directly affect

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proprioception through mechanisms other than pain, such as neural compromise through disc

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herniation or spinal stenosis or calcification of connective tissue in ankylosing spondylitis.

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Results obtained from conference proceedings and theses were excluded.

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Data Collection

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4 Two researchers (MT, SJM) independently extracted results from included studies.

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Information regarding study design, participant characteristics (inclusion/exclusion criteria,

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number, age and gender compositions and pain and disability measures), test protocols,

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outcomes measured and key findings (mean and SD of test performance and comparison of

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results between groups) were extracted from the full text of included articles. Only data on

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proprioception measurements gathered without the addition of extra manipulations intended

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to influence lumbar proprioception were considered for analysis. If numerical data were not

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reported in the paper, authors were contacted to determine if they could provide data. Results

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were categorised and analysed according to which proprioception test was used and the

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position in which tests were performed, as this has a significant effect on proprioceptive

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acuity.11

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Quality Assessment

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All included studies were assessed using a quality assessment checklist. This checklist

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includes relevant criteria obtained from the Downs and Black Scale12 and the CASP “case-

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control” tool13 along with other criteria devised for this review, giving a total of 19 criteria to

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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

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checklist and disparities were resolved by discussion, or, if that failed, consultation with a

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third reviewer (JvD). Final decisions were reached through consensus. No studies were

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excluded based on methodological quality. The checklist is presented in Textbox 1.

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Statistical Analysis

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Methodological quality was compared between studies that found and studies that do not find

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significant differences in proprioception between patients with LBP and controls using a two

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tailed Mann-Whitney U test (α=0.05).

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Results appropriate for meta-analysis were combined to a pooled standard mean difference by

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entering means and standard deviations of errors in proprioception tests reported in individual

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studies into Review Manager 5.314,a after rounding to one decimal place. Meta-analyses were

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grouped according to LBP subgroups, given our aims, and according to proprioception

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measurement methods and testing position. This is because different proprioception

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measurement methods are poorly correlated with each other15 and testing position has been

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shown to influence proprioceptive acuity.11 When studies reported proprioceptive data in

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multiple directions within the same testing position, means and standard deviations were

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pooled to give a single result for inclusion in meta-analysis. The inverse variance weighting

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method and random effects model were used to pool data. Heterogeneity was quantitatively

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analysed via the I2 test. If meta-analysis was not possible, the significance of differences in

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mean error between patients with LBP and controls was examined and a descriptive synthesis

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of results was performed.

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RESULTS

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Literature search

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The search identified 647 studies after removing duplicates. Screening of titles and abstracts

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left 47 studies. Further scrutiny of full text articles led to the final inclusion of 22 studies in

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the review. A detailed flowchart of the literature search is presented in Figure 1.

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Characteristics of included studies

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1 Twenty-one studies (1203 participants) compared patients with LBP with controls using cross

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sectional designs.16-35 One of these studies recruited patients36 and compared results with

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matched controls described in a separate study.37 One study (292 participants) examined

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possible links between lumbar proprioception and LBP development using prospective

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longitudinal designs.38 Five studies did not adequately report numerical data.16, 19, 28, 29, 33

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Emails were sent to all lead authors of these studies but only one author provided data for one

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study.28

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All studies defined LBP as lumbar pain without a specific established cause. Fourteen studies

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included patients with LBP of over 3 months duration,16, 17, 19-23, 25, 28-30, 32, 33, 36 four studies

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included participants with recurrent LBP,16, 19, 24, 27 one study included patients with LBP of

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over 2 weeks duration26 and five studies did not have criteria regarding LBP duration.18, 27, 31,

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34, 35

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vestibular impairment and lower limb symptoms. Some studies also excluded participants

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who had undergone spinal surgery16, 18, 19, 22, 25, 26, 28-31, 33-36 or motor control training,18, 31

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participants with psychological impairment21, 32 and participants who were pregnant or

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breastfeeding.17, 19, 20, 22, 27-30, 32 All studies defined controls as participants without a history of

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LBP.

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All studies excluded participants with systemic disease, neurological impairment,

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Some studies had additional criteria. One study required patients to have a minimum pain

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intensity on the Visual Analogue Scale (VAS)/Numerical Pain Rating Scale (NPRS) of

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3/10,17 while two studies required a minimum VAS of 5/10.20, 29 Three studies required at

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least a 50% reduction in lumbar range of motion (ROM).20, 28, 29 Two studies required patients 10 | P a g e


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to have LBP-related impairment in physical function.26, 33 Two studies required patients to

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possess flexion patterns of motor control impairment according to the O’Sullivan

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classification of LBP.30, 31 Further details regarding demographic data and inclusion and

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exclusion criteria are presented in Table 2.

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Subgrouping of low back pain

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Two studies sub-grouped patients using the O’Sullivan classification into flexion or extension

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patterns of motor control impairment.17, 32 Patients with flexion patterns adopt flexed lumbar

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postures, with pain provocation occurring with flexion and easing with extension.39, 40

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Patients with extension patterns adopt hyperextended lumbar postures, with pain provocation

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occurring with extension and easing with flexion.39, 40

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One study sub-grouped patients using a classification of “mild” and “significant” LBP.27

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“Significant” LBP was defined as LBP greater than 4/10 on NPRS at its worst, at least one

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episode of LBP in the past year greater than 1 week duration, greater than 20% disability on

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the Oswestry Disability Index and the need for pharmacological treatment or reduction of

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activity in the past year. “Mild” LBP was LBP that did not fit the criteria for “significant”

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LBP.

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Methods of measuring lumbar proprioception

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4 Twenty-one studies measured lumbar proprioception using joint repositioning sense (JRS)

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tests (Tables 3-4).16-32, 34-36, 38 Three studies measured lumbar proprioception using threshold

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to detection of passive motion (TTDPM),25, 33, 38 with two of these studies including

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directional motion perception (DMP) (Table 5).25, 38 Two studies used both JRS and

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TTDPM.25, 38

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Joint repositioning sense

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The JRS test measures how well a participant can replicate a “target position” of the lumbar

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spine. These are presented through visual feedback, manual guidance or verbal feedback.

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After presentation of the “target position”, the participant is moved out of the position and

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asked to replicate it actively (active JRS) or to indicate when they have been moved into the

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position passively (passive JRS).

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The outcome measure is the difference between the participant’s reproduction of the “target

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position” and the actual “target position.” There are three possible quantifications of this:

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absolute error (AE) is the unsigned difference between positions, constant error (CE) is the

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signed difference between positions and variable error (VE) is the standard deviation of CE.

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This review primarily considers AE as it was the most commonly used among included

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studies.

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Twenty studies used active JRS to measure lumbar proprioception,16-32, 34, 36, 38 three studies

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used passive JRS25, 35, 38 and two studies used both.25, 38 There was substantial variation in test

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protocols between studies. A variety of measurement devices were used, including electronic

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sensors, electro-goniometers, custom lumbar motion devices and tape measures. “Target

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positions” ranged from neutral lumbar spinal postures to targets in pelvic tilting and lumbar

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flexion, extension, lateral flexion and rotation. “Target positions” were also presented with

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varying modalities and time limits to memorise positions. However, all studies testing passive

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JRS used a movement velocity of 1°/second.

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The number of measurement and practice trials varied widely between included studies. The

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number of measurement trials performed ranged from 2 to 36 while the number of practice

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trials performed before starting measurement trials ranged from 0 to 12. One interesting

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variation was a cross-sectional study which required repositioning within 10% range of the

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“target position” in 5 consecutive practice trials with visual feedback before starting

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measurement trials and allowed an unlimited number of practice trials to achieve this.19

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Although this study found no significant difference in active JRS between patients and

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controls, some patients required significantly more practice trials (mean 69.4, 95% CI 59.2 to

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79.0) than controls (mean 41.7, 95% CI 35.0 to 48.5).

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Threshold to detection of passive motion

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4 The TTDPM test measures sensitivity to detection of movement. Starting from a neutral

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lumbar spine posture, participants undergo passive lumbar movement in custom devices at

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constant velocity and indicate the earliest point that they sense a positional change. This can

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be combined with DMP, where participants indicate the direction of the passive movement.

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Outcome measures are the smallest ROM at which the participant reported movement

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(TTDPM) and the direction of movement reported compared to the correct direction (DMP).

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Three studies used TTDPM to measure lumbar proprioception.25, 33, 38 Two of these studies

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used DMP alongside TTDPM by only recording TTDPM trials when participants correctly

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identified the direction of motion.25, 38 The number of measurement trials ranged from 5 to

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21, with trials performed in both directions within the specified plane of movement. One

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study did not report the number of practice trials given before measurement trials,33 while

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two studies gave 2 practice trials in each plane of motion with visual feedback.25, 38 All three

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studies used similar motion devices in tests of lumbar rotation and one study assessed

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TTDPM in lateral flexion and flexion/extension.25 Two studies used a movement velocity of

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0.1°/second and one study used a velocity of 1°/second.

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Methodological quality of included studies

2 3 Methodological quality of all studies is shown in Table 6. Among the cross-sectional trials

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the average quality score was 14.3 (lowest 11, highest 17) out of a maximum 19. The one

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prospective study scored 13 out of 16.

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Certain criteria in the quality checklist were poorly addressed. Only one study described the

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treatment history of patients with LBP,25 five studies justified their sample size as

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appropriate17, 26, 27, 32, 34 and six studies referenced or gathered data reporting their outcome

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measures as having high reliability.16, 21, 22, 26, 33, 34 Only six studies included all participant

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demographics and characteristics in appropriate detail,17, 19, 24, 25, 27, 38 with the most common

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characteristic not reported being average LBP duration. Only nine studies provided definitive

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evidence that patients and controls were recruited from the same population.17, 19, 20, 27, 30, 31, 33,

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34, 38

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Many criteria were well addressed. All studies adequately stated their objective(s), had

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appropriate designs, described inclusion and exclusion criteria in appropriate detail, recruited

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appropriate controls, described their outcome measures, used objective measurement

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instruments and reported results obtained through appropriate statistical analyses. Most

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studies recruited clinically representative patients,16-19, 21, 22, 26-33, 35 reported effect sizes16-18, 20-

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36, 38

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confounders in their results analysis and interpretation.16-20, 22, 24-26, 28-31, 33-36, 38

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and the random variability of their data16-18, 20-32, 34-36, 38 and recognised and addressed

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1 There was no difference in quality scores between the twelve cross-sectional studies that

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found at least one significant difference in proprioception between patients and controls

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(median 14)18, 20-22, 25, 26, 29-33, 35 and the nine cross-sectional studies that found no significant

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differences in proprioception (median 14)16, 17, 19, 23, 24, 27, 28, 34, 36 (Mann-Whitney U 52.5,

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p=0.92).

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Comparisons of lumbar proprioception between patients with LBP

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and controls

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Patients compared with controls

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Meta-analysis of 8 studies measuring AE during active JRS in sitting positions revealed

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significantly impaired proprioception in patients with LBP compared with controls (pooled

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standard mean difference 0.97, 95% CI 0.31 to 1.64, I2 90%) (Figure 2). Meta-analysis of 7

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studies measuring AE during active JRS in standing positions revealed no significant

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difference in proprioception between patients and controls (pooled standard mean difference

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0.41, 95% CI -0.07 to 0.89, I2 79%) (Figure 3). One study measured active JRS in four point

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kneeling and found a 2.4° higher mean AE in patients (mean AE 8.1°, SD 14.4) compared

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with controls (mean AE 5.7°, SD 8.1) (p6 months

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LBP >12 weeks of VAS >3/10 experienced most days of week

28 LBP

No peripheral pain, neurological impairment, lumbar spine surgery

28

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Asell

No pelvic or abdominal pain in last 12 months

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pants

Not pregnant or 6 months

(2005)19

No neurological impairment, severe scoliosis, previous spinal surgery,

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systemic disease

Controls

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Not taking pain medication

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16 LBP

40.9 (11.4), 38.2 (10.7), 11M, 5F

9M, 6F

15 LBP

40.1 (6.1)

38.5 (5.9)

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Gender not

Gender not

Controls

reported

reported

(2011)20

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LBP of VAS >5/10, lumbar ROM 3 months duration

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Georgy

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Not currently pregnant or breastfeeding

No inner ear pathology, neurological impairment, systemic disease Not currently pregnant or breastfeeding

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(1998)21

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Hidalgo

CS

(2013)22

LBP with or without leg pain as far as knee > 1 year duration No neurological impairment, mental disorders, further medical

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problems

Controls

LBP without radiation into leg >6 months

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lumbar spine surgery

Controls

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LBP >2 years

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(2011)23

CS

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Kara

10 LBP

No vestibular disease, systemic disease, neurological impairment,

Not pregnant 8

20 LBP,

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Gill

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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

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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

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Still working No neurological impairment

group (CS

LBP >3 months

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(1999)36

Single

30M,32F

8M, 10F

29 (5),

23, 5M, 5F*

Controls

20 LBP

surgery

Controls

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LBP >3 months

24 LBP 24

knee

Controls

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No history of spinal surgery, neurological impairment, pain below

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(2010)25

CS

18

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analysis) 11 Lee

38.2 (10.7) 24.6 (4)

No neurological impairment, previous back, abdominal or chest

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62 LBP

11M, 9F

42.6

42.4 (9.0),

(13.7),

14M, 10F

11M, 13F

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limb symptoms, untreated systemic disease

Controls

Chronic or recurrent LBP Not pregnant or 2 weeks with mild-moderate impairment of physical function

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CS

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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)

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CS

(2000) (1)28

LBP >3 months, lumbar ROM 5/10,

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No severe scoliosis, neurological impairment, lower limb problems Not currently pregnant or lactating

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(2000) (2)29

CS

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15 Newcomer

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Not currently pregnant or lactating

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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

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16 O’Sullivan CS (2003)31

LBP >3 months in subgroup of flexion pattern lumbar segmental instability (O’Sullivan classification)

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trunk

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LBP >3 months in subgroup of flexion pattern of motor control impairment (O’Sullivan classification) No previous back surgery

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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


Visual feedback via

Visual

10

computer screen data feedback

RI PT

Electro-


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


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


sensors Sitting


Researcher manual

3

reported

Nil

5

Researcher verbal

Not

18 (3 each

Flex/Ext, LF, LF (L & R), Rot (L


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 &


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


RI PT

Standing

Researcher manual

SC

15 Newcomer Fastrak

guidance, 5 second

M AN U

(2003)31

hold

17 O’Sullivan Strain


monitor

(2012)32

3D

Sitting &

kinematic

Standing

motion analysis system


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