Severe Low Back Pain Research Articles

Physical Performance, Anthropometrics and Functional Characteristics Influence the Intensity of Nonspecific Chronic Low Back Pain in Military Police Officers.

Background: Chronic low back pain (CLBP) is a serious problem in Military Police Officers (MPO), which accounts for up to 45% of the sick leave rates. It has been assumed that the strength and the endurance of trunk flexor and extensor muscles are CLPB key factors, but it is not known whether these attributes are related to pain intensity. It was aimed to determine whether the strength and endurance of trunk flexor and extensor muscles differ in MPO with no pain (CON; n = 24), moderate (MOD; n = 42), and severe (SEV; n = 37) nonspecific chronic low back pain (CLBP). Methods: The peak torque and endurance test of trunk flexor (PTF.BM−1) and extensor (PTE.BM−1) muscles were compared. A multiple regression analysis was used to identify pain intensity predictors in all groups (PAIN) and according to pain intensity (MOD and SEV). Results: The PTF.BM−1 was negatively related to pain and was a significant predictor, irrespective of pain intensity (PAIN). Conclusion: When pain intensity was considered the PTF.BM−1 and PTE.BM−1 explained the pain in the MOD, while the PTE.BM−1 and service time explained pain intensity in the SEV. Endurance of the flexor and extensor muscles was not related to pain intensity. These results indicated that training protocols must emphasize specific strengthening routines.

Relationship Between Varus Thrust During Gait and Low Back Pain in Individuals With Knee Osteoarthritis.

To test the hypothesis that varus thrust visualized during gait is associated with a higher prevalence of low back pain (LBP) in individuals with knee osteoarthritis (OA). Individuals with knee OA (Kellgren/Lawrence grade ≥1) underwent a gait observation to assess varus thrust. The participants identified LBP and its severity using questionnaires. Logistic regression analyses were performed to examine the association between varus thrust and LBP. We included 205 participants (mean age 68.19 years; 72.20% women). A total of 45 participants (22.0%) showed varus thrust in their painful knee, in whom 31 (68.89%) and 18 (40.00%) were identified as having any LBP and moderate-to-severe LBP (numerical rating scale ≥4 points), respectively. Patients with varus thrust demonstrated a 3.6-fold higher risk of the presence of moderate-to-severe LBP (95% confidence interval [95% CI] 1.62-8.10). In patients with LBP, the presence of varus thrust was associated with more severe LBP intensity (proportional odds ratio 2.25 [95% CI 1.02-4.96]). This study highlights the novel relationship between varus thrust and LBP, which supports the idea of a biomechanical link, the so-called knee-spine syndrome. These findings provide new insight for clarifying the pathogenesis of LBP related to knee OA.

Moderate or severe low back pain is associated with body mass index amongst community-dwelling older Australians

ObjectiveLow back pain is prevalent in older populations and modifiable risk factors may include being overweight or obese. This study aimed to describe the prevalence and impact of moderate or severe low back pain in community-dwelling older adults and its association with body mass index (BMI). MethodsCross-sectional study involving 16,439 Australians aged ≥70 years. Logistic regression was used to describe associations between the presence or absence of moderate or severe low back pain experienced on most days with BMI. Analyses were conducted separately for males and females, and controlled for age and depression at baseline. ResultsOf 14,155 pain question respondents, 11 % of males (n = 710/6475) and 18 % of females (n = 1391/7680) reported moderate or severe low back pain (total 15 %, n = 2101/14,155). Of those reporting moderate or severe low back pain (n = 2101), 55 % reported taking pain-relieving medication regularly, and 29 % reported that the pain regularly interfered with sleep, 37 % with walking, and 47 % with day to day activities. When age and depression were controlled for, there was a statistically significant (p < 0.001) association between moderate or severe low back pain and being overweight (females: odds ratio OR = 1.50, 95 % confidence interval CI = 1.27−1.76) or obese (males: OR = 2.23, 95 %CI = 1.77−2.80 and females: OR = 2.91, 95 %CI = 2.48−3.42). ConclusionModerate or severe low back pain is common, has a significant impact, and is associated with either an overweight or obese BMI among community-dwelling Australians aged ≥70 years.

Icariin Ameliorates Lower Back Pain in Rats via Suppressing the Secretion of Cytokine-Induced Neutrophil Chemoatractant-1.

Purpose To investigate whether icariin (ICA), a well-known medicine extracted from the stem and leaf of Epimedium brevicornum Maxim, had analgesic effect on lower back pain (LBP) in rats. Methods In a puncture-induced LBP rat model, the severity of LBP was quantified using the paw/foot withdrawal threshold method after intragastric administration of ICA at a dosage of 50 mg/kg/d or 100 mg/kg/d. The pain-related peptides of substance P (SP) and calcitonin gene-related peptide (CGRP) were also measured in intervertebral disc (IVD) tissue using RT-PCR after ICA treatment. In addition, the expression of cytokine-induced neutrophil chemoattractant-1 (CINC-1) in IVD was quantified using RT-PCR and ELISA examination. Results ICA treatment resulted in a significant amelioration of mechanical allodynia in a dose-response manner, and the analgesic effect could last for two weeks even during the washout period. More importantly, the mechanism of analgesic pharmacological effect in ICA was to suppress the upregulated CINC-1, the homolog of IL-8 in rats, which is a crucial proalgesic factor contributing to LBP, in IVDs. Conclusion ICA is a novel herbal extract to relieve LBP, and it may be a promising alternative pain killer in the future.

Community Pharmacist’s Role in Detecting Low Back Pain, and Patient Attitudes—A Cross-Sectional Observational Study in Italian Community Pharmacies

Background: Low back pain (LBP) is one of the most frequent diseases for which patients seek advice in a community pharmacy. The study aimed to evaluate the feasibility of the administration by community pharmacists of questionnaires to assess the LBP intensity and disability degree in patients entering community pharmacies and the attitudes they have toward pain management by pharmacological and non-pharmacological strategies. Methods: An explorative, cross-sectional, observational, and quantitative study was performed. Twelve Italian community pharmacists were asked to submit a questionnaire on LBP to patients visiting their pharmacies. The questionnaire included a pain intensity scale, and two validated tools: the Roland and Morris Disability Questionnaire (RMDQ) and the Start Back Screening Tool (SBST) to determine the degree and risk of patient disability, respectively. Results: 872 patients filled out the questionnaires in 6 months. No statistical differences between genders (p > 0.30) were recorded for pain intensity (Female: median score 6, IQR 4–7; Male: median scores 5, IQR 4–7; p > 0.30) and disability associated with LBP (RMDQ high-disability level: Females, 14.7%, Males, 15.0%; p > 0.90). Most of the patients (69%) reported a low degree of disability, but the risk of disability was medium and high in 36% and 18% of them, respectively (p < 0.05). About 14% of patients declare to never seek for physician’s advice despite their medium-high degree of disability. Conclusion: The study demonstrated the feasibility of validated tools for assessing the degree and risk of disability in LBP patients administrable in community pharmacies. Moreover, the community pharmacy resulted in an important care portal for patients suffering from moderate LBP and for intercepting patients who suffered from severe LBP but had never reported their problem to their physician.

Fatigue severity and fatigue sensitivity: relations to anxiety, depression, pain catastrophizing, and pain severity among adults with severe fatigue and chronic low back pain

Chronic low back pain is the second leading cause of disability in the United States, and it is often associated with severe fatigue. However, little is known about individual differences that may be related to poorer mental health and pain among individuals with severe fatigue and chronic low back pain. The aim of the current investigation was to explore the role of fatigue severity and fatigue sensitivity in terms of anxiety and depressive symptoms, pain catastrophizing, pain interference, and pain severity among 783 adults with severe fatigue and chronic low back pain. Results suggest that fatigue severity and fatigue sensitivity were statistically significant predictors for anxiety, depression, pain interference, and pain catastrophizing. However, only fatigue sensitivity significantly predicted pain severity. Overall, the current study provides initial support for the role of fatigue severity and fatigue sensitivity in the presence of mental and physical health complaints among individuals with severe fatigue and chronic low back pain.

Point-of-care Ultrasound Identification of Iliopsoas Abscess in Emergency Department: A Case Report.

IntroductionThe iliopsoas muscle is a rare place for an abscess to collect. While these abscesses can have high mortality, they are often misdiagnosed. The use of point-of-care ultrasound (POCUS) can aid in earlier diagnosis.Case ReportA 45-year-old male presented to the emergency department (ED) with severe lower back pain. The pain radiated to both of his legs and was associated with fever, weight loss, and malaise. The differential diagnosis for this patient was broad. A POCUS was performed at the bedside and revealed bilateral iliopsoas abscesses. This finding was then confirmed by computed tomography.ConclusionIn this case report we will discuss how to identify an iliopsoas abscess using POCUS in ED patients, and the utility of POCUS to facilitate an expedited diagnosis.

C-Arm–Free Circumferential Minimally Invasive Surgery for Adult Spinal Deformity: Technical Note

Circumferential minimally invasive surgery (cMIS), as a technique for reducing the complications of adult spinal deformity surgery, is receiving considerable attention. Conventional cMIS is performed using intraoperative fluoroscopy. In this work, we describe a new cMIS technique without using C-arm fluoroscopy for correcting adult spinal deformities. A 70-year-old woman with symptomatic adult spinal deformity was referred to our hospital. The patient's daily life has been affected by severe low back pain for more than 4 years. The surgery was performed without C-arm fluoroscopy. The percutaneous pedicle screws and intervertebral cages were inserted only under navigation guidance. The patient was successfully treated with surgery, and her low back pain was well controlled. Her clinical outcomes were as follows: Oswestry Disability Index improved from 64% to 14% and the low back pain visual analog scale score improved from 75 mm to 24 mm at 1 year of final follow-up. C-arm-free cMIS for adult spinal deformity is a useful technique that reduces percutaneous screw and cage misplacement. With this new technique, the surgeons and the operation room staff can avoid the risk of an adverse event of intraoperative radiation.

EVALUATION OF PHYSICAL EXERCISE'S EFFECTS ON LOW BACK PAIN AMONG UNIVERSITY STUDENTS WITH SHORT FORM-36 AND OSWESTRY DISABILITY INDEX

Aims: This study aims to investigate the main effects of physical exercise on lower back pain with the Short Form-36 Health Survey and Oswestry Disability Index scores. Methods: University students between 18-25 years old who suffer from low back pain were enrolled in the study. Short Form-36 Health Survey and Oswestry Disability Index were used as the reference scales of lower back pain and quality of life, respectively. There are some questions in the questionnaire to scale the average comfort of the place they sleep and sit during the day, which is the result of the Personal Comfort Score. The Mann-Whitney U test was used for non-normal distributed variables. Correlation and Linear Regression were used to analyze data. SPSS 25.0 was used for all statistical analysis. Results: A total of 139 university students (94 females, 45 males) were included in the study. The median age was 20 years (IQR=2) for female students and 20 years (IQR=1) for male students. Oswestry Disability Index scores of fe- male students were higher, while Short Form-36 scores were lower than the male students. Male students' physical functioning scores were higher than female students. Each one-unit increase in Personal Comfort Score is associated with an increase in the rate between the energy/fatigue (3.34 units). Body Mass Index considerably affected the pain and Oswestry Disability Score, an increase in one unit of baseline BMI upsurged the Short Form-36 pain score to 0.13, and Oswestry disability score to 0.55. Conc- lusion: In our study, Body Mass Index is found to be associated with Oswestry Disability Index and Short Form-36 score, which are used for the severity of low back pain and defining the life quality and of patients. PCS had a positive correlation between energy/fatigue. In addition, There was a positive correlation between physical exercise and general health score.

Pyogenic spondylodiscitis of the lumbar spine related to anastomotic fistula after surgery for esophageal cancer: a case report

BackgroundPyogenic spondylodiscitis is an extremely rare complication of esophagectomy for esophageal cancer.Case presentationA 70-year-old Japanese man, with a previous medical history of type 2 diabetes mellitus, coronary artery disease, and laryngeal cancer, received neoadjuvant chemotherapy and underwent thoracoscopic esophagectomy with gastric tube reconstruction for advanced esophageal cancer. Cervical esophagogastrostomy with circular-stapled end-to-side anastomosis was performed. However, partial necrosis in the gastric tube developed to form refractory anastomotic fistula. Two months after the initial surgery, debridement and free jejunal transfer reconstruction with the pectoralis major muscle flap were performed. Although the postoperative course of the second surgery was uneventful, the patient complained of severe lower back pain and fever. The patient was diagnosed with pyogenic spondylodiscitis according to the results of the magnetic resonance imaging. Enterobacter cloacae were isolated from the arterial blood culture. Sensitive antibiotics were administered continuously, and the patient required to use a lumbar corset for 2 months. Subsequently, his physiological signs and symptoms had completely disappeared.ConclusionTo the best of our knowledge, this case study is the first study that reported pyogenic spondylodiscitis of the lumbar spine, a complication of cervical anastomotic fistula after surgery for advanced esophageal cancer.

Lumbar spine metastasis in a breast cancer survivor after twelve years of disease-free survival

Spine metastasis is a common occurrence in breast cancer. The median time of spine metastasis from the diagnosis of breast cancer is approximately 3 years. In this case report, a 55 years old woman presented with insidious onset and progressively worsening severe low back pain. Spine MRI revealed L4-S1 heterogeneous marrow signal changes with L5 vertebral body collapse. She had undergone surgery, radiation, and chemotherapy for breast cancer 12 years prior. Although she had not received any anticancer treatment for 12 years, but she has been on regular follow up with the oncology team with no clinical evidence of local tumour recurrence. She had laminectomy and biopsy and the histological diagnosis was metastatic adenocarcinoma from breast cancer. She had palliative external beam radiation therapy and systemic chemotherapy with improvement in Karnofsky performance. We present a case of dormant micro metastasis re-activated 12 years after perceived cure for breast cancer.

Cross-Sectional Survey on Burnout and Musculoskeletal Disorders in Greek and Cypriot Occupational Therapists

Background: Occupational therapy is a physically, psychologically and cognitively demanding job. This study aims to explore the epidemiology of musculoskeletal injuries, mental issues, and burnout in occupational therapy practitioners in Greece and Cyprus.Method: A survey was conducted, including the Patient Health Questionnaire (PHQ-9), the Oldenburg Burnout Inventory, and the Nordic Musculoskeletal Questionnaire.Results: Out of 247 respondents, 70% reported severe lower back pain, 9.7% of Greek occupational therapists were in the moderate and high PHQ-9 scale, while disengagement and exhaustion were found 2.026 (±0.54) and 2.592 (±0.533) respectively.Conclusion: High rates of burnout, correlated with psychological and musculoskeletal disorders were identified in both countries. Work-related stress and musculoskeletal disorders may be more evident in countries hit by recession.

Anterior Spinal Fusion Using Autologous Bone Grafting via the Lateral Approach with Posterior Short-Range Instrumentation for Lumbar Pyogenic Spondylitis with Vertebral Bone Destruction Enables Early Ambulation and Prevents Spinal Deformity.

Introduction Pyogenic spondylitis of the lumbar spine markedly decreases the ability to perform activities of daily living and causes severe low back pain. The challenge is to improve low back pain and activities of daily living performance earlier and prevent post-infection sequelae, and conservative treatment with antibiotics is the mainstay of treatment. Methods In the present study, patients who were unable to walk following lumbar pyogenic spondylitis even in the subacute phase after successful infection control, showing bone defects expanding from endplate to vertebral body in CT, were treated with posterior percutaneous short-range instrumentation and anterior autogenous bone grafting (group S, n = 10) or with conservative treatment alone (group C, n = 10). Acute cases of absolute surgical indication with paralytic symptoms and mild cases who could walk by antibiotics administration were excluded. The two groups were compared regarding the post-treatment change in C-reactive protein level, duration of bed rest, and post-infection local spinal deformities (local scoliosis angle in the coronal plane and local kyphosis angle in the sagittal plane). Results Compared with group C, group S took a significantly shorter time for the C-reactive protein level to return to normal and required a significantly shorter duration of bed rest. Furthermore, surgery prevented the formation of kyphosis and scoliosis, while group C developed local kyphosis. Conclusions The minimally invasive surgical method of posterior percutaneous short-range instrumentation and anterior autogenous bone grafting effectively enables early control of pain and maintenance of locomotive function and prevents spinal deformity in patients with lumbar pyogenic spondylitis in the subacute phase with advanced vertebral bone destruction.

A comparison of application frequency of physical therapy modalities in patients with chronic mechanical low back pain.

This study aims to evaluate the effects of physical therapy modalities five days a week versus twice a week with a three-day interval on pain, depression, and functional disability in patients with chronic mechanical low back pain. Between June 2018 and November 2018, a total of 60 patients (39 females, 21 males; mean age 41.0±6.8 years; range, 25 to 55 years) with chronic mechanical low back pain were included. The patients were divided into two groups: Group 1 (n=30) received physical therapy five days a week for a total of 15 sessions, while Group 2 (n=30) received physical therapy twice a week with a three-day interval for a total of six sessions. Per protocol, all patients were applied hot pack for 20 min, followed by conventional transcutaneous electrical nerve stimulation (TENS) for 20 min and therapeutic ultrasound (US) for 10 min in each session. All patients were given exercise training and were instructed to do twice a day up to four weeks after the completion of physical therapy sessions. The severity of low back pain was evaluated using the visual analog scale (VAS), the severity of depression using the Beck Depression Inventory (BDI), and functional disability using the Oswestry Disability Index (ODI). All patients were evaluated before and after physical therapy and at four weeks. The results were compared between the groups. There was no statistically significant difference in the age, gender, body mass index, occupation, VAS, BDI, and ODI scores at the time of randomization (p>0.05). Intra-group analysis showed a significant improvement in all parameters after physical therapy compared to pre-treatment values and at four weeks compared to the post-treatment values (p<0.001). The differences of changes were used for the inter- group analysis which revealed a difference of change in favor of improvement was significantly higher in Group 2 than Group 1 (p<0.001). There was no significant difference between the post-treatment values and values at four weeks (p>0.05). Our study results suggest that both physical therapy modalities applied five days week and twice a week are effective in pain, depression, and functional disability. However, physical therapy protocol applied twice a week yields more improvement, indicating that it is more advantageous with less cost and lost workdays.

Fever and Severe Low-Back Pain

Fever and Severe Low-Back Pain

Assessment of Motion and Muscle Activation Impacts on Low Back Pain during Pregnancy Using an Inertial Measurement Unit

Specific physiological changes during pregnancy exert excessive strain on muscles such as the erector spinae (ES) and contribute to low back pain (LBP). The link between LBP and sit-to-stand (STS) motion has previously been investigated through motion analysis using an inertial measurement unit (IMU); however, the factors leading to LBP have not been revealed. Moreover, clinicians require an effective assessment method for reducing the physical burden on pregnant women. Therefore, the investigation of the relationships between motion, muscle load calculated from musculoskeletal model for pregnancy, and the severity of LBP during STS in pregnant women was conducted. Furthermore, this study proposes a method for assessing motion and muscle load during STS using an IMU. The relationship among (i) motion evaluation indices and ES muscle torque, and (ii) the ES torque and the intensity of LBP during STS was investigated. As the results, significant positive correlations were observed between (i) the angular velocity of the torso in the sagittal plane and ES torque, and (ii) two types of evaluation indices of ES torque and intensity of LBP. The proposed method by an IMU attached to the torso could effectively assess ES load related to LBP during STS in pregnant women.

The Swedish Back School in Chronic Low Back Pain. Part II. Factors Predicting the Outcome

The aim of the study was to analyse the factors predicting the outcome of the Swedish back school and spontaneous recovery in chronic low back pain. The predicting variables describing the treatment group (n = 95) and the control group (n = 93) at the initiation of study included sociodemographic factors, variables related to work, severity of low back pain, and a number of clinical measurements and evaluations. The Oswestry Low Back Pain Disability Questionnaire was used for judging recovery factors. It was found that the best predictor for the outcome of the treatment and for spontaneous recovery was work satisfaction.

A controlled study on the outcome of inpatient and outpatient treatment of low back pain. Part III. Long-term follow-up of pain, disability, and compliance

The long-term outcome results of inpatient and outpatient treatment of low back pain (LBP) were studied in 476 subjects (aged 35-54, 63% men) randomly assigned to three study groups: inpatients (n = 157), outpatients (n = 159), and controls (n = 160). The study included changes in the severity of low back pain, grade and disability, compliance with self-care, data on disability pensions, and days of sickness allowance during a 2.5-year follow-up period. These variables were used as outcome criteria. Pain and disability had decreased significantly in the two treated groups up to the 3-month follow-up. LBP was still a little slighter in the inpatients at the 1.5-year and 22-month follow-ups, but there were no significant differences between the groups in disability caused by LBP. The refresher programme carried out 1.5 years after the first one did not bring about as clear short-term improvement in pain and disability as the first treatment. During the whole 2.5-year follow-up compliance with self-care was better in the two treated groups, especially in the inpatients. Days of sickness allowance had increased somewhat more in the controls than in the inpatients during the follow-up. No differences between the groups were found in the number of disability pensions granted.

SUN-199 A Case of Ectopic Cushing’s Syndrome with Major Complications Leading to Treatment Dilemmas

Background: Ectopic ACTH syndrome is an uncommon cause of Cushing’s syndrome and patients are at high risk for serious complications including infections, thromboses, cardiovascular and neuropsychiatric complications; therefore, swift diagnosis and treatment is needed. Clinical Case: A 63-year old woman presented with lower extremity edema and severe lower back pain. She also reported a 2 month history of polyuria, polydipsia, and headaches. Initial labs showed hypernatremia, hypokalemia, alkalemia and hyperglycemia and an 8AM cortisol of 61.9 mcg/dL (N 5-25 mcg/dL) with an ACTH of 367 pg/mL (N 6-50pg/mL). Imaging showed a right middle lobe lung mass and 3 vertebral body compression fractures. A failed attempt at biopsy of the lung mass resulted in pneumothorax, air embolism, stroke, and cardiac arrest with shock liver. She was then transferred to our tertiary care center.On arrival at our center, her examination was notable for hypertension, upper and lower extremity edema and 4/5 strength in her right shoulder and hip flexor. She had left hemiparesis and a depressed mood. No facial plethora, acanthosis, buffalo hump or striae were observed. Her 24-hour Urinary Free cortisol (UFC) was 1,176 mcg/dL (n 3.5-45 mcg/24H) and her 8AM cortisol after 8 mg of dexamethasone was 58.3 mcg/dL (N <1.8mcg/dL).A pituitary MRI did not identify a lesion, and petrosal sinus sampling was considered too high-risk due to recent infarct and cerebral edema. A PET/CT-scan showed increased uptake in the right lung nodule, enlarged hyperactive adrenals, and a retroperitoneal lymph node.The patient’s course was further complicated by diffuse deep vein thromboses of her left leg and a subsequent retroperitoneal bleed while on anticoagulation, as well as an E.coli urinary tract infection.Interdisciplinary discussions regarding options for surgical management were ongoing, however given the patient’s fragile medical state, the endocrine team initiated medical therapy to treat her hypercortisolism while awaiting surgical decision. Initially, a continuous etomidate infusion was used that resulted in a 50% reduction in 24Hr UFC. When her liver function improved, she was transitioned to ketoconazole. She ultimately underwent a right middle lobectomy, revealing a 2.3cm typical carcinoid tumor with strongly diffusely positive ACTH staining on pathology. A day after surgery her ACTH level was 12 pg/mL, though cortisol was still elevated at 55.5 mcg/dL. Cortisol declined to 3.3 mcg/dL within one week. Her neuropsychiatric symptoms reversed almost entirely and she was discharged on a steroid taper. Conclusion: Ectopic ACTH syndrome is a rare paraneoplastic syndrome with significant comorbidity. In many cases, surgical excision can induce profound and rapid reversal of many of the symptoms of cortisol excess; however, if surgery is delayed, prompt medical treatment is vital to prevent compounding complications.

Are there differences in lifting technique between those with and without low back pain? A systematic review

Background and aims To systemically review the literature to compare freestyle lifting technique, by muscle activity and kinematics, between people with and without low back pain (LBP). Methods Five databases were searched along with manual searches of retrieved articles by a single reviewer. Studies were included if they compared a freestyle lifting activity between participants with and without LBP. Data were extracted by two reviewers, and studies were appraised using the CASP tool for case-control studies. Results Nine studies were eligible. Heterogeneity did not allow for meta-analysis. Most studies (n = 8 studies) reported that people with LBP lift differently to pain-free controls. Specifically, people with LBP lift more slowly (n = 6 studies), use their legs more than their back especially when initiating lifting (n = 3 studies), and jerk less during lifting (n = 1 studies). Furthermore, the four larger studies involving people with more severe LBP also showed that people with LBP lift with less spinal range of motion and greater trunk muscle activity for a longer period. Conclusions People with LBP move slower, stiffer, and with a deeper knee bend than pain-free people during freestyle lifting tasks. Interestingly, such a lifting style mirrors how people, with and without LBP, are often told how to lift during manual handling training. The cross-sectional nature of the comparisons does not allow for causation to be determined. Implications The changes described may show embodiment of cautious movement, and the drive to protect the back. There may be value in exploring whether adopting a lifting style closer to that of pain-free people could help reduce LBP.