ABSTRACT
This study verified the capacity of motor tests related to musculoskeletal fitness to predict young adults with low back pain (LBP). The sample consisted of 377 participants of both sexes, who answered the Nordic questionnaire for LBP and performed the sit-and-reach, horizontal jump, 1-min sit-up, Sorensen, and side plank tests. All tests showed low accuracy (AUC < 0.70), although the Sorensen (p = 0.03) and side plank (p = 0.00) tests showed statistical significance. Therefore, despite the low accuracy, the cutoff point identified in the side plank test (< 41 sec.) and Sorensen (< 89 sec.) can be used with some caution to predict young adults with LBP.
Keywords: Physical fitness; Musculoskeletal pain; Students; Diagnosis
RESUMO
Este estudo verificou a capacidade de testes motores relacionados com aptidão musculoesquelética para predizer jovens adultos com dor lombar (DL). A amostra foi composta por 377 participantes de ambos os sexos, que responderam ao questionário nórdico para DL e realizaram os testes sentar-e-alcançar, salto horizontal, abdominal em 1-min, Sorensen e prancha lateral. Todos os testes apresentaram baixa acurácia (AUC < 0,70), embora os testes Sorensen (p = 0,03) e prancha lateral (p = 0,00) tenham apresentado significância estatística. Desta forma, apesar da baixa acurácia, o ponto de corte identificado no teste prancha lateral (< 41 seg.) e Sorensen (< 89 seg.) podem ser utilizados com certa cautela para predizer jovens adultos com DL.
Palavras-chave: Aptidão física; Dor musculoesquelética; Alunos; Diagnóstico
RESUMEN
Este estudio verificó la capacidad de las pruebas motoras relacionadas con la aptitud musculoesquelética para predecir adultos jóvenes con dolor lumbar. La muestra estuvo compuesta por 377 participantes de ambos sexos, quienes respondieron el cuestionario nórdico de dolor lumbar y realizaron las pruebas de sentar y alcanzar, salto horizontal, abdominales de 1 min, Sorensen y plancha lateral. Todas las pruebas mostraron baja precisión (AUC < 0,70), aunque las pruebas de Sorensen (p = 0,03) y de plancha lateral (p = 0,00) mostraron significación estadística. Por lo tanto, a pesar de la baja precisión, el punto de corte identificado en la prueba de plancha lateral (< 41 s) y Sorensen (< 89 s) se puede utilizar con cierta precaución para predecir adultos jóvenes con dolor lumbar.
Palabras-clave: Aptitud física; Dolor musculoesquelético; Estudiantes; Diagnóstico
INTRODUCTION
Low back pain (LBP) stands out as a predominant contributor to years lived with disability in Brazil (Vos et al., 2017). Affecting around 10% of the young adult population, this percentage escalates to 15-20% among older adults, with a higher prevalence observed in women (Wu et al., 2020). It has been recognized that the incidence of LBP at a young age is an important risk factor for low back pain throughout adulthood (Moreno, 2017; Coenen et al., 2017). In a young population, different factors have been associated with a greater probability of experiencing LBP, including decreased strength and resistance of the muscles responsible for stabilizing the spine, such as the abdominal and paravertebral muscles (Sutanto et al., 2022; Linek et al., 2020; Suh et al., 2019).
Based on this assumption, some authors have endeavored to identify the predictive capacity of motor tests related to musculoskeletal fitness in identifying young people at greater risk of developing LBP (Dorneles et al., 2016; Saint-Maurice et al., 2015). However, existing studies are still incipient, yielding inconsistent results, with most motor tests demonstrating low accuracy for identifying young people with LBP, especially in males, as demonstrated by a recent systematic review (Fraser et al., 2021). The difficulty in predicting LBP probably occurs due to the fact that it is a disease with a multivariate prognosis, in which different psychosocial factors are associated with disability (Yamada et al., 2023).
Recognizing the importance of establishing cutoff points based on health criteria, such as LBP, through motor tests indicating musculoskeletal fitness, emerges as a pertinent alternative. These criteria can be employed by physical exercise professionals in initial screenings targeting the population of interest. This proactive approach enables the design of early intervention strategies, thus reducing the occurrence of LBP throughout life. This demand has been emphasized by a committee on measures of physical fitness and health outcomes in young people, stressing the importance of identifying motor tests with predictive capabilities for musculoskeletal outcomes (Pate et al., 2012). Therefore, the present study aimed to evaluate the predictive capacity of motor tests indicating musculoskeletal fitness in identifying young adults at risk of developing LBP.
METHODS
The research was conducted in the city of Jacarezinho, state of Paraná, Brazil. To determine the number of participants, the sample calculation considered the 1-min sit-up test, with a sensitivity of 84.4% for identifying young people with low back pain, based on a previously carried out pilot study (Oliveira et al., 2017b). Employing a half-amplitude of 0.04 as the maximum acceptable error and a confidence interval of 95%, the minimum sample size required was 306 young people. To account for potential sample losses, an additional 20% increase was applied, resulting in the recruitment of 377 young university students of both sexes (224 women and 153 men) aged between 18 and 22 from the Universidade Estadual do Norte do Paraná.
A non-probability, convenience sampling was used. Students who agreed to participate and met the inclusion criteria signed an Informed Consent Form. The study was approved by the university's Human Research Ethics Committee (number of project 2,697,284). The inclusion criteria were: a) age > 18 years; b) be regularly enrolled in an undergraduate course; c) absence of ongoing medical treatment; d) no continuous use of medication; e) no surgical procedures within the last six months; f) absence of musculoskeletal injuries; g) non-pregnant status; h) no physical or cognitive disabilities. All assessment procedures were carried out in a single moment, lasting approximately 60 minutes: application of the low back pain questionnaire followed by motor tests.
LBP assessment questionnaire
The instrument used to assess LBP was an adapted version of a Nordic questionnaire (Kuorinka et al., 1987), validated for young Brazilians (Oliveira et al., 2017a), previously adopted by a study with similar objectives (Saint-Maurice et al., 2015). Comprising 15 items, each garnering 1 point for affirmative responses and zero points for negative answers, the questionnaire served as a comprehensive assessment tool. Participants scoring > 7 points were classified as experiencing LBP (Kuorinka et al., 1987). This approach, encompassing various pain domains, not only aligns with the original work of Kuorinka et al. (1987) but also demonstrates robustness, particularly suitable for young populations.
Motor tests
Five motor tests, indicators of musculoskeletal fitness, were randomly administered:
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sit-and-reach – sitting on the floor, participants kept their knees extended with their feet on the Wells bench. The torso was flexed forward so that the hands could reach as far as possible. Participants performed three attempts, with the best distance in centimeters recorded for analysis (Wells and Dillon, 1952);
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1-min sit-up – participants executed trunk flexion while maintaining hands crossed against the chest. During abdominal movements, the scapulae should touch the ground and the forearm should touch the thigh at the beginning and end of each repetition, respectively. The number of correct repetitions in one minute was recorded. (Guedes and Guedes, 2006);
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Sorensen – in the prone position, participants positioned their trunk beyond a stretcher, starting from the anterior superior iliac crest. With arms crossed against the chest, the neutral trunk position was maintained for as long as possible, with the duration recorded in seconds (Demoulin et al., 2006);
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side plank – in lateral decubitus, participants kept their forearms and feet flat on the floor, keeping their hips elevated, in order to maintain alignment between feet, hips and head. The neutral position was maintained for as long as possible, measured in seconds (Tong et al., 2014);
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horizontal jump – the participants were positioned behind a demarcation line and had to jump as far as possible. Three jumps were allowed and the best one was considered for analysis, according to the distance in centimeters between the starting line and the heel closest to it after the jump. (Guedes and Guedes, 2006).
These tests were chosen because they involve the direct action of the muscular region (abdominal, paravertebral and gluteal muscles) that affects people with LBP. No adverse events were reported by participants during testing.
Statistical analysis
To assess the normality of the data, the Kolmogorov-Smirnov test was used. The groups were compared using the Mann-Whitney U test. Assessment of the predictive capacity of motor tests to identify young adults with LBP was determined by the area under the ROC Curve (Receiver Operating Characteristic), with 95% confidence intervals. Accuracy values, expressed as the area under the curve (AUC), were categorized into three ranges: 0.50-0.69 (low accuracy); 0.70-0.89 (moderate accuracy); and ≥ 0.90 (high accuracy) (Fischer et al., 2003). The determination of optimal cutoff points (criteria) for each motor test, maximizing accuracy, was based on the properties of sensitivity (ability to identify true positives) and specificity (ability to identify true negatives). All data were processed using the SPSS 22.0 program (SPSS Corp., Chicago, IL, USA), with the exception of procedures relating to the ROC Curve, which were processed using the MedCalc 17.5 program (Acacialaan, Ostend, Belgium). The confidence interval admitted for all tests was 95% (p < 0.05).
RESULTS
Figure 1 presents the STARD diagram, which reports the flow of participants during the study. There were no inconclusive data for the standard reference test (low back pain questionnaire) and all participants were able to complete the motor tests (index tests). Table 1 presents the sample characterization and a gender comparison. Men had significantly higher body mass, height, and body mass index. In relation to motor tests, men performed better in the horizontal jump, 1-min sit-up and side plank.
In total, 23.6% of the sample reported experiencing LBP (women 27.7% and man 17.6%). Table 2 presents the comparison between participants with and without LBP. Participants with LBP exhibited significantly poorer performance in the Sorensen and side plank tests. Notably, among women with LBP, age, body mass, and height were significantly higher, accompanied by inferior performance in the Sorensen and side plank tests. Men with LBP had significantly greater height, with no differences for the other variables.
Table 3 presents the accuracy of motor tests to predict young adults with LBP. Notably, all tests presented low overall accuracy (AUC < 0.70). However, the Sorensen test demonstrated statistical significance of the entire sample, while the side plank test exhibited significance for both the entire sample and female participants. Specifically, for the entire sample, participants who sustained the Sorensen test for less than 89 seconds and the side plank test for less than 41 seconds were significantly more likely to experience LBP. In the context of female participants, those who held the side plank position for less than 31 seconds were significantly more likely to report LBP.
DISCUSSION
The primary aim of this study was to assess the predictive capacity of five motor tests in identifying young adults with LBP. When comparing participants with and without LBP, the isometric resistance tests that assess the stability of the muscles in the lumbo-pelvic region (Sorensen and side plank) were the only ones that showed a significant difference between the groups. In other words, participants with LBP showed significantly worse performance on these tests compared to their counterparts without LBP. Furthermore, these same tests were the only ones that showed significant accuracy in identifying young adults with LBP, although with low predictive power. In this sense, tests that assess flexibility, horizontal jump distance and dynamic resistance of the abdominal muscles may not be effective indicators to distinguish young adults with and without LBP.
These findings align with the work of Saint-Maurice et al. (2015), who, in their evaluation of American children and young individuals, reported low predictive capacity for musculoskeletal fitness tests in identifying those with LBP, except for the flexibility test for girls (AUC = 0.80). Likewise, a recent systematic review found low discriminatory capacity for musculoskeletal pain in young people, both in tests involving muscular resistance and flexibility (Fraser et al., 2021).
The present study’s observational of the enhanced predictive capacity of isometric tests, particularly those related to lumbo-pelvic stabilization, can be attributed to the close association between low back pain and the weakness of deep muscles in this region, such as the tranversus abdominis, multifidus, and internal obliques. These muscles, crucial for stabilization, are most effectively engaged in isometric exercises (Moon et al., 2013). A systematic review with meta-analysis (Sutanto et al., 2022) found positive results in reducing pain and disability in patients with LBP through long-term training programs that include isometric trunk strengthening exercises.
Despite the overall low accuracy, the Sorensen test and side plank showed statistical significance for predicting LBP considering the entire sample. Consequently, the cutoff points identified in these tests can be used with some caution to predict a greater risk of LBP in individuals who remain < 89 seconds in the Sorensen test and < 41 seconds in the side plank test, with some ability to identify the true positive cases (sensitivity of 53.9% and 59.5%, respectively) and true negatives (specificity of 54.8% and 62.5% respectively). When stratifying by gender, the side plank test showed statistical significance in predicting LBP in women who remained < 31 seconds in the side plank test, with some ability to identify true positive cases (sensitivity of 61.2%) and true negative cases (specificity of 61.1%).
In light of the limited existing research on health criteria for musculoskeletal outcomes, this study contributes valuable insights. The study’s limitations, including the small participant pool, especially in gender-stratified analyses, and the retrospective nature of the questionnaire introducing potential recall bias, are acknowledged. However, the subjective and multifactorial nature of low back pain justifies the use of this questionnaire. We also did not evaluate the difference between participants with and without LBP for walking speed, gait mechanics and energy expenditure. Among these variables, a previous study observed significant differences between people with and without LBP for walking speed (Henchoz et al., 2015), which can be considered by future studies. Additionally, caution is advised when extrapolating findings to other populations, given the study’s composition of young mixed-race university adults in Brazil.
CONCLUSION
The findings from this study underscore the limited accuracy of motor tests assessing musculoskeletal fitness, specifically related to flexibility, strength, and resistance of spinal stabilizing muscles, in identifying young adults with LBP. Nevertheless, a cautious application of the cutoff point derived from the side plank test may be considered for young female adults. Despite its low precision, the side plank test exhibited statistically significant results in this demographic.
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FUNDING
None.
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Publication Dates
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Publication in this collection
10 Jan 2025 -
Date of issue
2024
History
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Received
09 Apr 2024 -
Accepted
16 Oct 2024