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Purpose: (1) Identification of musculoskeletal risk factors for healthcare providers suffering low back pain (LBP) and the creation of risk profiles for those individuals and (2) analyze the impact of a workplace wellness program on healthcare providers who suffer from low back pain., Methods: A total of 3040 employees at an academic healthcare center underwent a computer-adaptive survey of health-related quality of life (HRQOL), biometric tests, and a disability and functional movement assessment as part of the workplace wellness program (WWP). Clinical interventions with a rehabilitation specialist were offered to employees identified as at risk for low back pain. Data collected were analyzed using descriptive methods and multivariable regressions to address the study objectives., Results: Of the 3040 healthcare providers enrolled in this study, 77% identified with non-specific LBP with greater weakness, numbness, reduced flexibility, and physical activity. The major predictive risk factors for LBP were Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference score, PROMIS fatigue, previous work injury, flexibility, numbness, PROMIS social function, level of education, and BMI. Healthcare providers with LBP who completed the WWP improved in most dimensions of HRQOL and disability and functional outcomes., Conclusions: A high proportion of healthcare providers suffer from LBP as a result of the nature of their work. Disability and functional outcomes measurements and PROMIS results quantitatively assess healthcare providers with LBP. Organizations can develop injury mitigation programs to target employees at high risk of LBP using the risk factors we identify. Completion of the WWP was associated with improvements in disability, HRQOL and functional measures., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Study Design: This is a retrospective cohort with multiple regression modeling., Objective: The aim is to develop a new method for estimating cone of economy (CoE) using a force plate rather than traditional motion capture., Background: Currently, most spinal deformity surgeons rely on static radiographic parameters for alignment, balance, and outcomes data alongside patient-reported outcome measures. The CoE, the stable region of upright posture, can be objectively measured to determine the efficiency and balance of the spine. Motion capture technology is currently used to collect data to calculate CoE, but this requires expensive and complex equipment, which is a barrier to widespread adoption and clinical use of CoE measurements. Force plates, which measure pressure, are less expensive and can be used in a clinical setting., Methods: Motion capture and a force plate were used to quantify the CoE of 473 subjects (423 spinal surgical candidates; 50 healthy controls; 271 females; age: 58.60 ± 15.27; height: 1.69 ± 0.13; weight: 81.07 ± 20.91), and a linear multiple regression model was used to predict CoE using force plate data in a human motion laboratory setting. Patients were required to stand erect with feet together and eyes open in their self-perceived balanced and natural position for a full minute while measures of sway and center of pressure (CoP) were recorded., Results: The CoP variable regression model successfully predicted CoE measurements. The variables that were used to predict vertical CoE were CoP coronal sway, CoP sagittal sway, and CoP total sway in several combinations. The coefficient of determination for the head total sway model indicated a 87.0% correlation (F(3,469) = 1044.14, p < 0.001). The coefficient of determination for the head sagittal sway model indicated a 69.2% correlation (F(3,469) = 351.70, p < 0.001). The coefficient of determination for the head coronal sway model indicated a 85.2% correlation (F(3,469) = 899.27, p < 0001)., Conclusion: Cone of economy was estimated from force plate data using center of pressure with high correlation without the use of motion capture in healthy controls and a variety of spine patients. This could lower the entry burden for measurement of the CoE in patients, enabling widespread use. This would provide surgeons objective global balance data, along with Haddas' CoE classification system, that could assist with surgical decision-making and facilitate objective monitoring surgical outcomes., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Study Design: A prospective cohort study OBJECTIVE: To determine a classification system for cone of economy (CoE) measurements that defines clinically significant changes in altered balance and to assess if the CoE measurements directly impacts patients reported outcome measures (PROMs). Preoperative functional data is a crucial component of determining patient disability and prognosis. The CoE has been theorized to be the foundation of biomechanical changes that leads to increased energy expenditure and disability in spine patients. PROMs have been developed to quantify the level of debilitation in spine patients but have various limitations., Methods: A total of 423 symptomatic adult patients with spine pathology completed a series of PROMs preoperatively including VAS, ODI, Tampa Scale for Kinesiophobia (TSK), Fear and Avoidance Beliefs Questionnaire (FABQ), and Demoralization (DS). Functional balance was tested in this group using a full-body reflective marker set to measure head and center of mass (CoM) sway., Results: PROMs scores were correlated with the magnitude of the CoE measurements. Patients were separated by the following proposed classification: CoM coronal sway > 1.5 cm, CoM sagittal sway > 3.0 cm, CoM total sway > 30.0 cm, head coronal sway > 3.0 cm, head sagittal sway > 6.0 cm, and head total sway > 60.0 cm. Significant differences were noted in the ODI (< 0.001), FABQ physical activity (< 0.001-0.009), DS (< 0.001-0.023), and TSK (< 0.001-0.032) across almost all planes of motion for both CoM and head sway. The ODI was most sensitive to the difference between groups across CoM and head sway planes with a mean ODI of 47.5-49.5 (p < 0.001) in the severe group versus 36.6-39.3 (p < 0.001) in the moderate group., Conclusions: By classifying CoE measurements by the cutoffs proposed, clinically significant alterations in balance can be quantified. Furthermore, this study demonstrates that across spinal pathology, higher magnitude CoE and range of sway measurements correlate with worsening PROMs. The Haddas' CoE classification system in this study helps to identify patients that may benefit from surgery and guide their postoperative prognosis., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The traditional teaching has been that proper function of a cervical disc replacement is dependent upon appropriate placement, which includes centering the device in the coronal plane. The purpose of this study was to identify the most reliable anatomical landmark for determining midline placement of an implant within the cervical disc space under fluoroscopy., Methods: Digital fluoroscopy images were taken for each cervical level at 0 °, 2.5 °, 5 °, 7.5 °, 10 °, and 15 ° from the mid-axis by rotating the C-arm beam of six cadavers. Thin-slice CT scanning of the same levels was subsequently performed. Three independent reviewers measured the distance between anatomic structures: (a) tip of the right uncinate; (b) medial border of the right pedicle; and (c) center of the spinous processes for different x-ray angles across cervical levels C3-7., Results: Both the uncinate and pedicle demonstrated superior overall accuracy to that of the spinous process (p ≤ 0.02) at all angles except at 0 ° for the pedicle where the difference was not statistically significant. Overall (pooled C3-7), the accuracy of the uncinate did not differ significantly from that of the pedicle at any fluoroscopic angle. The center of the spinous process measurement was particularly sensitive to deviations from the perfect anteroposterior fluoroscopy image., Conclusions: The results of this investigation suggest that the tip of the uncinate and the medial border of the pedicle are more accurate measures of midline in the cervical spine than the center of the spinous process and are less susceptible to inadvertent off-axis imaging.

Introduction: The Gait Deviation Index (GDI) is a composite measure of gait abnormality derived from lower-limb joint range-of-motion which is increasingly being reported for clinical gait analysis among neurologic and orthopedic patients. A GDI score of 100 is representative of healthy individuals and decreasing scores represent a greater abnormality. Preliminary data is needed to help assess the utility of GDI as a measure of compromised gait among spine patients and to provide reference values for commonly treated pathologies., Methods: GDI scores were obtained from healthy adults and four symptomatic degeneration groups: cervical spondylotic myelopathy (CSM), adult degenerative scoliosis (ADS), and single-level lumbar degeneration (LD). Clinical gait analysis was done using a three-dimensional motion tracking system. Evaluations were done 1 week prior to surgical intervention for degeneration groups. Two-sample t-tests were used to compare degenerative cohorts to healthy controls and for inter-cohort comparisons. Pearson correlations were used to test for significant relationships between GDI and walking speed., Results: Degenerative cohorts all showed significantly lower (worse) GDI scores compared to healthy (all p < 0.001). CSM patients showed the best GDI scores with an average of 90, and LD patients showed the worst GDI scores with an average of 86. Worsening GDI significantly correlated with decreased walking speed among ADS patients., Conclusion: Composite metrics like GDI provide a tempting means to summarize nuanced and complex gait characteristics into a single, comparable value among cohorts. The results of this study provide preliminary GDI scores for common degenerative spine pathologies. These slides can be retrieved under Electronic Supplementary Material.

Study Design: A nonrandomized, prospective, concurrent control cohort study., Objective: To further develop cone of economy (CoE) measurements by identifying compensatory mechanisms at the extremes of the CoE and comparing balance control strategies in a group of adult degenerative scoliosis (ADS) patients with non-scoliotic controls. The CoE concept was first proposed by Dubousset and is frequently referred to when assessing balance in spinal deformity patients. Recently, a method that quantifies the CoE of individual patients through 3D video kinematic and electromyography data was developed. However, this method lacks measurements that describe the motor control strategies utilized by spinal disorder patients to maintain balance., Patient Sample: Twenty ADS patients and 15 non-scoliotic controls., Methods: All test subjects were fitted with a full body marker set. Each subject performed a series of functional balance tests (Romberg's with eyes opened) while being recorded in a human motion capture system. Three-dimensional CoE dimensions, range of sway (RoS), overall sway and lower extremity and trunk range of motion (RoM) were measured and analyzed., Results: Patients with ADS demonstrated greater overall sway and RoS in the sagittal and coronal planes compared to controls. Moreover, ADS patients presented with more hip flexion and trunk flexion at maximal points of sway and more ankle, knee, hip and trunk RoM when swaying in comparison with controls., Conclusions: ADS patients have larger CoE dimensions and increased sway when compared to non-scoliotic controls. ADS patients rely on a hip balance control "strategy" and lower extremity RoM to maintain balance, which differed from control subjects. Unlike prior attempts to define compensatory mechanisms in ADS patients, the described technique utilizes dynamic, three-dimensional measurements to define what is occurring within the CoE. By expanding on prior CoE measurements, we were able to define a unique dynamic balance control strategy for each patient.

Purpose: Use gait analysis to establish and detail the clinically relevant components of normal human gait, analyze the gait characteristics for those afflicted with spinal pathology, and identify those aspects of human gait that correlate with pre- and postoperative patient function and outcomes., Methods: Twenty patients with adult degenerative scoliosis (ADS), 20 patients with cervical spondylotic myelopathy (CSM), and 15 healthy volunteers performed over-ground gait trials with a comfortable self-selected speed using video cameras to measure patient motion, surface electromyography (EMG) to record muscle activity, and force plates to record ground reaction force (GRF). Gait distance and temporal parameters, ankle, knee, hip, pelvic, and trunk range of motion (ROM), duration of lower extremity EMG activity and peak vertical GRF were measured., Results: Patients with ADS and CSM exhibited a significantly slower gait speed, decrease in step length, cadence, longer stride time, stance time, double support time, and an increase in step width compared to those in the control group. These patients also exhibited a significantly different ankle, knee, pelvic, and trunk ROM. Moreover, spinal disorder patients exhibited a significantly longer duration of rectus femoris, semitendinosus, tibialis anterior and medial gastrocnemius muscle activity along with an altered vertical GRF pattern., Conclusions: Gait analysis provides an objective measure of functional gait in healthy controls as well as those with ADS and CSM. This study established and detailed some of the important kinematic and kinetic variables of gait in patients with spinal disorders. We recommend that spine care providers use gait analysis as part of their clinical evaluation to provide an objective measure of function. These slides can be retrieved under Electronic Supplementary Material.

Study Design: A non-randomized, prospective, concurrent control cohort study., Objective: The purpose of this study is to develop and evaluate a method to quantify the dimensions of the cone of economy (COE) and the energy expenditure associated with maintaining a balanced posture within the COE, scoliosis patients and compare them to matched non-scoliotic controls in a group of adult degenerative. Balance is defined as the ability of the human body to maintain its center of mass (COM) within the base of support with minimal postural sway. The cone of economy refers to the stable region of upright standing posture. The underlying assumption is that deviating outside one's individual cone challenges the balance mechanisms. Adult degenerative scoliosis (ADS) patients exhibit a variety of postural changes within their COE, involving the spine, pelvis and lower extremities, in their effort to compensate for the altered posture., Methods: Ten ADS patients and ten non-scoliotic volunteers performed a series of functional balance tests. The dimensions of the COE and the energy expenditure related to maintaining balance within the COE were measured using a human motion video capture system and dynamic surface electromyography., Results: ADS patients presented more COM sway in the sagittal (ADS: 1.59 cm vs. H: 0.61 cm; p = 0.049) and coronal (ADS: 2.84 cm vs. H: 1.72 cm; p = 0.046) directions in comparison to the non-scoliotic control. ADS patients presented with more COM (ADS: 33.30 cm vs. H: 19.13 cm; p = 0.039) and head (ADS: 31.06 cm vs. H: 19.13 cm; p = 0.013) displacements in comparison to the non-scoliotic controls. Scoliosis patients expended more muscle activity to maintain static standing, as manifest by increased muscle activity in their erector spinae (ADS: 37.16 mV vs. H: 20.31 mV; p = 0.050), and gluteus maximus (ADS: 33.12 mV vs. H: 12.09 mV; p = 0.001) muscles., Conclusions: We were able to develop and evaluate a method that quantifies the COE boundaries, COM displacement, and amount of sway within the COE along with the energy expenditure for a specific patient. This method of COE measurement will enable spine care practitioners to objectively evaluate their patients in an effort to determine the most appropriate treatment options, and in objectively documenting the effectiveness of their intervention.

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Purpose: To examine the influence of volitional preemptive abdominal contraction (VPAC) and recurrent low back pain (rLBP) on trunk mechanics and neuromuscular control during a symmetric lifting task., Methods: A 2 × 2 crossover mixed design was used to examine the effects of VPAC and group. Thirty-seven healthy individuals and 32 rLBP individuals performed symmetric box lifting trials with and without VPAC to a 1-m height table 3D trunk, pelvis, and hip joint angle and electromyographic magnitude variables were obtained. Selected variables were analyzed using ANOVA., Results: The VPAC induced differences in joint kinematics and muscle activity in rLBP and healthy subjects during symmetric lifting. A significant two-way interaction effect was observed for the semitendinosus activity. The VPAC increased external oblique muscle activity, reduced erector spinae and multifidus muscles activity, and induced greater trunk flexion angle, greater trunk side flexion angle, and greater hip flexion angle, and decreased pelvis obliquity angle in both groups. In addition, the rLBP subjects presented with a reduced external oblique and gluteus maximus muscle activity, greater erector spinae and multifidus muscles activity, and greater pelvis posterior tilt angle., Conclusions: Our results provide evidence that a VPAC strategy performed during symmetric lifting may potentially reduce exposure to biomechanical factors that can contribute to lumbar spine injury. The hamstring muscles may play an important role in achieving pelvic balance during the lifting maneuver. Incorporating the VPAC during dynamic stressful activities appears to help improve sensorimotor control and facilitate positioning of the lower extremities and the pelvis, while protecting the lumbar spine.