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Sadler et al.

BMC Musculoskeletal Disorders (2017) 18:179
DOI 10.1186/s12891-017-1534-0

RESEARCH ARTICLE Open Access

Restriction in lateral bending range of
motion, lumbar lordosis, and hamstring
flexibility predicts the development of low
back pain: a systematic review of
prospective cohort studies
Sean G Sadler1*, Martin J Spink1, Alan Ho2, Xanne Janse De Jonge3 and Vivienne H Chuter1

Abstract
Background: Low back pain (LBP) is an increasingly common condition worldwide with significant costs associated
with its management. Identification of musculoskeletal risk factors that can be treated clinically before the
development of LBP could reduce costs and improve the quality of life of individuals. Therefore the aim was to
systematically review prospective cohort studies investigating lower back and / or lower limb musculoskeletal risk
factors in the development of LBP.
Methods: MEDLINE, EMBASE, AMED, CINAHL, SPORTDiscus, and the Cochrane Library were searched from inception
to February 2016. No age, gender or occupational restrictions of participants were applied. Articles had to be
published in English and have a 12 month follow-up period. Musculoskeletal risk factors were defined as any
osseous, ligamentous, or muscular structure that was quantifiably measured at baseline. Studies were excluded if
participants were pregnant, diagnosed with cancer, or had previous low back surgery. Two authors independently
reviewed and selected relevant articles. Methodological quality was evaluated independently by two reviewers
using a generic tool for observational studies.
Results: Twelve articles which evaluated musculoskeletal risk factors for the development of low back pain in 5459
participants were included. Individual meta-analyses were conducted based on risk factors common between
studies. Meta-analysis revealed that reduced lateral flexion range of motion (OR = 0.41, 95% CI 0.24-0.73, p = 0.002),
limited lumbar lordosis (OR = 0.73, 95% CI 0.55-0.98, p = 0.034), and restricted hamstring range of motion (OR = 0.96,
95% CI 0.94-0.98, p = 0.001) were significantly associated with the development of low back pain. Meta-analyses on
lumbar extension range of motion, quadriceps flexibility, fingertip to floor distance, lumbar flexion range of motion,
back muscle strength, back muscle endurance, abdominal strength, erector spinae cross sectional area, and
quadratus lumborum cross sectional area showed non-significant results.
Conclusion: In summary, we found that a restriction in lateral flexion and hamstring range of motion as well as
limited lumbar lordosis were associated with an increased risk of developing LBP. Future research should aim to
measure additional lower limb musculoskeletal risk factors, have follow up periods of 6-12 months, adopt a
standardised definition of LBP, and only include participants who have no history of LBP.
Keywords: Low back pain, Systematic review, Risk factors, Prospective cohort studies, Meta-analysis

* Correspondence: sean.sadler@newcastle.edu.au
1
Discipline of Podiatry, University of Newcastle, Ourimbah, Australia
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

which has a significant negative impact on the there was limited evidence to support a range of muscu- quality of life of sufferers [1]. that have specifically investigated musculoskeletal by third reviewer (VC) was needed. Studies could potentially decreasing the absorption of force. particularly in low and middle income systematic review in adolescents and children found that countries. AMED and The Cochrane spinal loading and reduce spinal stability with altered Library was conducted from inception to February 2016. No disagreements occurred tivity in the adult population [18–23]. ing the possibility of developing LBP [17]. frequent bending and twisting. LBP. reviewers (SS and MS). There have been few systematic evaluations of muscu. or muscular structure that was quantifiably strain on pelvic muscles. A lower limb musculoskeletal risk factors in the develop- number of possible musculoskeletal risk factors have also ment of LBP over 12 months.Sadler et al. or had itionally. increasing pain [15. who developed LBP. risk factors in the development of LBP in all age groups. development of injuries. which may encourage an anterior pelvic tilt [12. although this is highly variable in study populations and variable follow-up times make and depends on the specific population investigated. Search strategy Dysfunction of muscles of the lumbopelvic-hip com. with no separate data for those Tight hamstring muscles may reduce the lumbar lordosis. Excessive foot pronation can limited to 12 months due to the possibility of other ex- lead to an internally rotated tibial and femoral position traneous variables influencing the development of LBP. The altered pelvis position is thought to increase the ligamentous. Further to this. 13]. tigating musculoskeletal risk factors with a 12 month strings [10. diagnosed with cancer. anxiety. and somatisation all having cohort studies that have investigated lower back and/or been linked to the development of the condition [4. Methods sociated socioeconomic burden of the condition reduced. Accurate identification of meta-analysis where appropriate. 5]. Secondary aims include been implicated in the development of LBP and verifica. Search terms were adapted for each of the databases particularly in a chronic form [6]. Study findings will be evaluated by LBP can be effectively treated. which measured at baseline. The it difficult to draw definitive conclusions. pants were pregnant. 11] have been associated with an increased follow-up were included. lumbar spine. Musculoskeletal risk factors were defined as any osseous. focussing on prospective articles investigating other risk Titles and abstracts were independently assessed by two factors such as psychosocial or work related physical ac. Studies were excluded if partici- may cause compression of the sciatic nerve [7. report LBP by any means. Similarly. Studies that investigated the strain on intervertebral discs. however. An electronic database search of MEDLINE. or mobility of the Low back pain (LBP) is an increasingly common condi. plex (core muscles) has been demonstrated to increase CINAHL. depression. The reference lists risk factors. the authors found no relationship between of included studies. Study selection loskeletal risk factors for LBP with the majority of work One reviewer conducted the electronic searches (SS). prolonged static pos. core muscle recruitment patterns a hallmark of LBP. For Only English language prospective cohort studies inves- example. abnormal (Additional file 1). systematic review that collectively evaluates the contri- uctivity. The PRISMA statement was used to lower limb function is proposed to reduce absorption structure this systematic review. differences in definitions with disability [2]. BMC Musculoskeletal Disorders (2017) 18:179 Page 2 of 15 Background trunk muscle endurance or strength. The aetiology of LBP is multifactorial with previous over the short to medium term is required. associated with LBP. the altered pelvic position is proposed to put previous low back surgery. The length of follow-up was risk of developing LBP. Add. excessive foot pronation [7–9] and tight ham. are alarming with costs to bution of lower back and lower limb musculoskeletal individuals and governments continuing to increase [1]. clinical guidelines. the differences from chronic pain [3]. Therefore a economic implications of early retirement and lost prod. of impact force and affect spinal loading with dysfunc- tion both distally and proximally in the lower limb Eligibility criteria suggested to contribute to the development of LBP. A tion worldwide. musculoskeletal risk factors may also offer a mechanism by which occurrence of LBP can be prevented and the as. 14]. SPORTDiscus. The growing impact of loskeletal risk factors for the development of LBP [24]. were also excluded. such as the piriformis. and recently . Of existing data in while screening for inclusion therefore no arbitration adults. the identification of the type and duration of LBP that tion of these may offer a potential mechanism by which participants develop. EMBASE. 16]. and the risk of developing LBP [18]. and increas. LBP globally is evidenced by recent research indicating Individual risk factors were demonstrated to be signifi- that LBP is now among the top ten causes of years lived cant in single studies. This systematic review aims to evaluate prospective tures. Lifetime prevalence of LBP is reported of LBP and measurement techniques between studies to be as high as 84% with approximately 23% suffering prevented meta-analyses.

were appropriate for full text review. After review.Sadler et al. in a meta-analysis [27]. A list of full text articles with Hedges methods [26]. Data extraction was conducted by of the meta-analyses. The I2 statistic factors in the development of LBP included a total of 5459 Fig. each criterion. packages Microsoft Excel 2016 and STATA 12 were used Included studies were awarded a ‘yes’. 1 PRISMA flow diagram . Results Study identification Statistical analysis Searchers retrieved a total of 3479 citations of which 114 Effect sizes were either obtained from studies if re. or ‘can’t tell’ for for statistical analyses. was used to assess the level of heterogeneity within each tentially eligible studies. 1). No disagreement occurred while assessing the quality of included studies. random effects models with Characteristics of included studies DerSimonian and Laird weights were used due to the The 12 articles [29–40] investigating musculoskeletal risk varying study designs and populations [27]. BMC Musculoskeletal Disorders (2017) 18:179 Page 3 of 15 published systematic reviews were also searched for po. [25]. 12 ported or calculated appropriately from proportions or articles were included while 102 were rejected based on means and standard deviations using Hasselblad and exclusion criteria (Fig. For all meta-analyses performed. There was insufficient information individual reasons for exclusion is included as a supple- in each study to allow more elaborate modelling that mentary file (Additional file 2). Software observational studies developed by Weightman et al. Statistical analysis to assess the risk of publication bias was not used as fewer than 10 Quality assessment studies were included in the meta-analysis and. might account for correlations between measures. in these Methodological assessment was performed independently instances. ‘no’. test power has been reported to be too low to by two reviewers (SS and JA) using a generic tool for distinguish chance from actual asymmetry [28]. In instances where a risk factor was one reviewer (SS) using a standardised data extraction common between two or more studies. it was combined form and cross-checked by a second reviewer (AH).

erector spinae cross-sectional area (CSA). al. significant association between restricted hamstring ROM and the risk of developing LBP (OR = 0. Each study in an interview. Additionally.24-0. [39] did pants in these studies.98. Alternatively. In addition. 39].73. [37] using different up period. or questionnaire. association between reduced lateral flexion ROM and ies only included participants with no recent history of the development of LBP (OR = 0. The effect sizes for all . 38]. starting from an upright position to the LBP [29.04 (1/0. abdominal strength. most satisfying the majority of the criteria on the quality p = 0.41) study [36] used the Nordic questionnaire while another which means that those participants with limited lateral study [33] just used a picture from the questionnaire flexion ROM have a 144% greater likelihood of develop- and asked participants if they had experienced LBP. Alterna- how the outcome of LBP was measured (Table 1). and hamstring flexibility. tors showed non-significant results and are included as quadriceps flexibility. No significant heterogeneity was detected (I2 = 29. The criterion regarding bias Three studies involving 1771 participants provided could not be assessed in the majority of cases due to lack data for hamstring ROM and were eligible for inclusion of reporting of steps involved in participant assessment in this meta-analysis (Fig. whereas Feldman et al. point that pain occurred or further motion could not be ing that those participants with a history of LBP were achieved (Table 3).304). fingertip to floor distance. 2). lateral bending included as a supplementary file. for lateral flexion ROM and were eligible for inclusion in tween the physical examination of participants and the this meta-analysis (Fig. 34]. 38. ing LBP. Ages in included studies and management. L1 and L4 respectively (Table 3). [38] used the straight leg there was a lack of reporting of cultural and ethical raise test. due to absence of this information.Sadler et al. with two of these studies stat. p = 0. p = 0. appraisal tool (Table 2). 95% Meta-analyses CI 0.9%. lumbar lordosis. geo- knee extension test (Table 3).41. 4). quadra- up period of 12 months with the exception of Milgrom et tus lumborum CSA. 3). factors common between studies. The analysis revealed a the type or duration of LBP that participants developed significant association between a reduction in lumbar lor- during follow up.44 (1/0. The analysis revealed a graphical information is reported in Table 1. p = 0.55-0. Fully annotated forest plots for the flexion ROM. It was Three studies involving 1364 participant provided data not possible to precisely determine the mean duration be. back muscle strength. Fortin et al. dosis and the risk of developing LBP (OR = 0. 40]. this can be expressed as an OR of 1. [40] used a numeric pain scale to assess Three studies involving 1657 participants provided LBP. [37] where the follow-up period was 14 weeks. 36. LBP [33. It remains unclear if a valid and reliable reference points. These studies asked participants. used a different device to measure lumbar lordosis with whether or not they experienced LBP during the follow Adams et al. All three studies period.8 [39] to 27 years [29]. p = 0.002) with a low and non-significant amount of Only a small number of studies provided details of heterogeneity present (I2 = 15.7%.96) or a 4% greater likelihood of develop- factors a combined meta-analysis was not appropriate. Two studies assessed lateral flexion ROM by measuring the distance did not state whether participants had a history of LBP that participants could slide their hand down their ipsi- [30. 95% CI 0. No significant heterogeneity was detected (I2 = 0%. however. Most studies [29–32. [35] results of included studies was difficult to determine as and Van Nieuwenhuyse et al. The analysis revealed a significant pain free at baseline [32. 37–39] simply stated data for lumbar lordosis and were eligible for inclusion that a questionnaire was completed by participants at in this meta-analysis (Fig. Mean ages in included studies development of their symptoms throughout the follow-up varied from 10 [35] to 27 years [29].883). 34. BMC Musculoskeletal Disorders (2017) 18:179 Page 4 of 15 participants (Table 1). 31.241). One tively. from which the angle was measured.98. The four remaining stud. 95% CI 0. p = 0.73.37 (1/0. gating the following 12 musculoskeletal risk factors were Meta-analyses on all other musculoskeletal risk fac- conducted: lumbar extension range of motion (ROM).96. this can be expressed as an OR of 2.034). back non-significant meta-analyses (Additional file 3) are muscle endurance. 35.001) which is equivalent to an OR Due to studies measuring different musculoskeletal risk of 1. while six included participants with a history of lateral thigh. [29] and Milgrom et al. no study identified not report a reference point. ROM. ing LBP in those participants with limited hamstring Individual meta-analyses were conducted based on risk ROM. 37. Kujala et al. All included studies had a follow. lumbar part of Table 3. studies varied from 12.73) or a 37% greater likelihood of Study quality developing LBP in people with restricted lumbar lordo- Studies generally performed well in terms of quality with sis.94-0. 32. Meta-analyses investi. Nissinen et al. Mean ages in included baseline and follow up. physical examination. the generalisability of ranged from 10 [35] to 26 years [38]. 35. of measurement tool was used to assess the LBP of partici. [31] used the passive characteristics of the study populations.

n = 23 n = 18 developed first time LBP (72. n = 28 (M). n = 128 (2% lost in follow up n = 13 developed first time LBP (out Mean age (years) = 48 Pain free at baseline: yes period) of 43 that reported no history of LBP Population = Twins at baseline.2%)). 56% F at follow up Region: Finland Page 5 of 15 .4 months) (23% lost in follow up period) LBP Population = University students Pain free at baseline: yes Gender = 74% F Region: Thailand Kountouris et al [34] n = 23 History of LBP: n = not stated Sports Medicine Physician and MRI. 69. survey) # that developed LBP in follow up year previous episode Adams et al [29] n = 403 History of LBP: n = 141 Self-administered postal questionnaire. 30.3%].Pain free at baseline: not stated n = 119 (14% lost in follow up period) first time LBP [11.4%) Population = Monozygotic twins Gender = 0% F Region: Finland Gibbons et al [32] n = 130 History of LBP: n = 85 (in past year) Telephone.g.3.1 Pain free at baseline: not stated lost in follow up period) (17.4%) developed first time Mean age (years) = 19.3 Population = athletes and non-athletes Gender = not stated. 13 Mean age (years) = not stated.2%)) Population = Adolescent students Gender = 47% F Region: Canada Sadler et al.3%) Mean age (years) = 24 Pain free at baseline: yes (0% lost in follow up period) Population = Elite fast bowlers Gender = 0% F Region: Australia Kujala et al [35] n = 138 History of LBP: n = 28 (in past year) Self-administered postal questionnaire. n = 98 (1% lost in follow n = 68 (recurrence or persistence of Mean age (yr) = 47.8%) 13. n = not reported Gender = 0% F for those 85 participants that declared Region: Finland a history of LBP in 12/12 before baseline testing Kanchanomai et al [33] n = 684 History of LBP: n = 0 (in past 3 Self-administered questionnaire. 30 Population = community members up period) (F) [first time LBP 6. range 10.3 Pain free at baseline: not stated up period) LBP. n = 524 n = 160 (23. n = 920 (1% percent lost in follow persistence of LBP]. n = 399 n = 159 (39. 185 (F) [recurrence or Mean age (yr) = not stated.Table 1 Summary of included studies (n = 12) Study Participants Description of LBP/determination of a Outcome measure (e. BMC Musculoskeletal Disorders (2017) 18:179 Fortin et al [40] n = 99 History of LBP: 68 Numeric pain scale. n = 502 (38% n = 65 developed first time LBP Mean age (yr) = 14. n = 24 (11 recurrence of LBP [39. range 30-60 Pain free at baseline: not stated telephone.5%) first time LBP Mean age (yr) = 27 Pain free at baseline: not stated (1% percent lost in follow up period) Population = Health care workers Gender = 92% F Region: United Kingdom Biering-Sorensen et al [30] n = 928 History of LBP: not stated Self-administered postal questionnaire or n = 170 (M).3%] Gender = 52% F Region: Denmark Feldman et al [31] n = 810 History of LBP: n = 125 Self-administered questionnaire.

Gender = 60% F 15. n = 859 (0% lost in follow (17. n = 52 (out of 337 that and distribution facilities reported LBP at baseline) reported LBP in 12/12 before testing. 9. n = not clear how n = 40 developed first time LBP (10.6%).4%) Region: Belgium F female.6%) Population = School children up period) Gender = 48% F Region: Finland Van Nieuwenhuyse et al n = 823 History of LBP: n = 337 (in past year) Self-administered questionnaire. M male.8 Pain free at baseline questionnaire.8%) Mean age (years) = not stated Pain free at baseline: yes follow up period) Population = blue and white collar workers Gender = 56% F Region: Finland Milgrom et al [37] n = 395 History of LBP: n = 0 Physical examination. BMC Musculoskeletal Disorders (2017) 18:179 [38] Mean age (years) = 26 Pain free at baseline: n = 688 (4 of the (16% lost in follow up period) 355 that reported no history of LBP at Population = workers at health care participants with history of LBP baseline.1%) Mean age (years) = 18 Pain free at baseline: not stated many were lost in follow up period Population = infantry recruits Gender = 0% F Region: Israel Nissinen et al [39] n = 859 History of LBP: n = 0 (in past year) Self-administered standardised pain n = 151 developed first time LBP Mean age (years) = 12.Table 1 Summary of included studies (n = 12) (Continued) Luoto et al [36] n = 167 History of LBP: n = 0 (in past year) Nordic questionnaire. n = 126 (25% lost in n = 33 developed first time LBP (19. n = 692 n = 34 developed first time LBP (out of Sadler et al. LBP low back pain Page 6 of 15 .

Are you confident with the authors' yes yes yes yes yes yes yes yes yes yes yes yes choice and use of statistical methods. Does the paper address a clearly yes yes yes yes yes yes yes yes yes yes yes yes focused issue? 3. Were all important outcomes/results yes yes yes yes yes no yes no no yes yes yes considered? 12. Is confounding and bias can’t tell can’t tell yes yes can’t tell yes yes yes can’t tell can’t tell can’t tell can’t tell considered? 6. Is the choice of study method yes yes yes yes yes yes yes yes yes yes yes yes appropriate? 4. BMC Musculoskeletal Disorders (2017) 18:179 appropriate? 5. Is the population studied yes yes yes yes yes yes yes yes yes yes yes yes Sadler et al. Are tables/graphs adequately labelled yes yes yes yes yes yes yes yes yes yes yes yes and understandable? 8.Table 2 Quality appraisal of included studies Adams Biering-Sorensen Feldman Fortin Gibbons Kanchanomai Kountouris Kujala Luoto Milgrom Nissinen Van Nieuwenhuyse et al [29] et al [30] et al [31] et al [40] et al [32] et al [33] et al [34] et al [35] et al [36] et al [37] et al [39] et al [38] 1. Was follow up for long enough? yes yes yes yes yes yes yes yes yes can’t tell yes yes 7. Accept for further use as Type IV yes yes yes yes yes yes yes yes yes yes yes yes evidence? Page 7 of 15 . What are the results of this piece of yes yes yes yes yes yes yes yes yes yes yes yes research? Are the authors' conclusions adequately supported by the information cited? 10. Can the results be applied to the can’t tell can’t tell can’t tell can’t tell can’t tell can’t tell can’t tell can’t tell can’t tell can’t tell Can’t tell can’t tell local situation? 11. Is the study relevant to the needs of yes yes yes yes yes yes yes yes yes yes yes yes the Project? 2. if employed? 9. Is any cost information provided? no yes no no no yes yes yes yes no yes yes 13.

as previ- analyses on the following risk factors: lumbar extension ous LBP has been shown to be a risk factor for the ROM. back muscle a cause and effect relationship difficult. number of included studies have resulted in these meta- analyses lacking power and generalisability [27]. 39]. as strength. hamstring flexibility. hamstring ROM meta-analyses. the authors were abdominal strength. 40]. most of which re. due to the small number of studies included the their study. and hamstring flexibility. but no CSA. and quadratus lumborum CSA the results from additional data were provided except for information these analyses can only be considered as a summary meas- from Adams et al. ever. Nevertheless. isometric itional information was required. The low of the odds ratios for this study. Although some demonstrated moderate methodological quality on the studies included only participants without a history of appraisal tool (Table 2). but did not report the results within addition. [29. due to the mixed populations of the included gated by the studies included in this review. 38. for the devel. quadratus tion of association and there are extremely limited data lumborum CSA. Further- Discussion more when interpreting all of the results of this systematic Our systematic review of the literature found 12 pro. the results of the meta-analyses are important results of our meta-analyses. restrictions in lateral flexion to improve the collective understanding of the nature ROM. 32. . How- Additional musculoskeletal risk factors were investi. 36. erector spinae contacted and the necessary data requested. abdominal strength. 31. 37. which was calculated LBP. To the authors knowledge these are the first as a standard mean difference because the figures were meta-analyses of these musculoskeletal risk factors to reported as continuous data. fingertip to floor distance. erector spinae CSA. most of which out a history of LBP must be considered. In such instances and when other add. a number included some par- range of musculoskeletal risk factors. demonstrate significant prospective relationships. ticipants who have previously experienced the condition lated to the lower back and pelvic region. these studies are interpreted in context of this. It is important that the results of opment of LBP with multiple studies allowing meta. however. and lumbar lordosis were of LBP. meta-analyses of back muscle strength. lumbar lordosis. studies and the close proximity of the upper band of were not combined in meta-analyses because they the confidence interval for the lumbar lordosis and were only measured in one study (Additional file 4). making the establishment of lumbar flexion ROM. In other studies. 35. some caution is advised Some studies did measure the same risk factors as when interpreting these significant meta-analyses. BMC Musculoskeletal Disorders (2017) 18:179 Page 8 of 15 Fig. 2 Annotated forest plot for lateral flexion range of motion and LBP meta-analyses were calculated as odds ratios except for found to increase the risk of participants developing the erector spinae meta-analysis. back muscle endurance. [29] which aided in the calculation ure and definitive conclusions cannot be drawn. quadriceps flexibility. These studies investigated a recent LBP [33. quadriceps flexibility.Sadler et al. the inclusion of study populations with and with- spective studies eligible for inclusion. development of LBP [23]. the majority of studies demonstrated a consistent direc- lateral bending ROM. review. Based on the available.

p = 0.96 (0.17 (0.001) 100 Back muscle strength Biering-Sorensen et al [30] Equipment: Strain gauge dynamometer 1.48-1.81 (0.98.61-1.24-0.70 (0.94-0.81) 16.16) 71. p = 0.59 Methods: Biering-Sorensen test Biering-Sorensen et al [30] Equipment: Stopwatch 0.98.002) 100 Lumbar lordosis Adams et al [29] Equipment: 3Space Isotrak device 0.80 Methods: Biering-Sorensen test Luoto et al [36] Equipment: Stopwatch 0.70-3.97 Methods: Biering-Sorensen test Kujala et al [35] Equipment: Stopwatch 1.2) 0.77) 12.23 Methods: Difference between middle finger position on ipsilateral thigh to most distal position of middle finger achieved in max lateral flexion Overall effect size (I-squared = 15. p = 0.53-6.49 (0.97.07) 42.7%.29-0.04 Method: Straight leg raise Overall effect size (I-squared = 0%. ipsilateral knee extended from 90° of flexion Kujala et al [35] Equipment: Hydrogoniometer 0.55-5.788) 1.00 (0. p = 0.15 Method: Spinal pantograph used to measure lordosis angle in an upright standing Overall effect size (I-squared = 29.62) 18.61) 17.Sadler et al.87 (0.9%.56) 11.93) 28. p = 0. p = 0.304) 0.034) 100 Hamstring flexibility Feldman et al [31] Equipment: Goniometer 0. BMC Musculoskeletal Disorders (2017) 18:179 Page 9 of 15 Table 3 Overview of significant and nonsignificant risk factors in meta-analyses Risk Factor Study Measurement technique Effect size (95% CI) Weight Lateral flexion range Adams et al [29] Equipment: 3Space Isotrak device 0.14) 16.16-1.94-0.85 (0. p = 0.65 Methods: Max isokinetic strength from forward flexion to upright standing Overall effect size (I-squared = 0%.56 (0.80 (0.98) 99.50 (0.57 Methods: Biering-Sorensen test Gibbons et al [32] Equipment: Stopwatch 0.241) 0.58 (0.42 (0.37 Method: Inclinometer place over spinous process of L4 and lordosis angle measured relative to horizontal Nissinen et al [39] Equipment: Spinal pantograph 0.06 of motion (ROM) Method: Sensors on sacrum and L1 spinous process measured degree change between upright standing and max lateral flexion Kujala et al [35] Equipment: Tape measure 0.86) 65.55-0.45) 0.73 (0.60-1.14-1.883) 0.35 Methods: Device attached to shoulders of participant and the MVC of 3 attempts of extension in upright standing Gibbons et al [32] Equipment: not clear 1.74) 17.05-0.41 (0.16) 46.83) 35.48 Method: Sensors on sacrum and L1 spinous process measured degrees of lordosis in upright standing Milgrom et al [37] Equipment: Cybex (EDI 320) inclinometer 0. p = 0.92 Method: Supine position with hip at 90°.73.38-0.26-2.49 (0.84 (0.20-2.88 (0.71 Methods: Difference between middle finger position on ipsilateral thigh to most distal position of middle finger achieved in max lateral flexion Van Nieuwenhuyse et al [38] Equipment: Tape measure 0.96 (0.29 (0.160) 100 Back muscle fatigability Adams et al [29] Equipment: Stopwatch 0.31-3.04 Method: Straight leg raise Van Nieuwenhuyse et al [38] Equipment: Inclinometer 1.11-0.06 Methods: Biering-Sorensen test .83-2.

00 (0.67) 50.976) 100 Fingertip to floor distance Biering-Sorensen et al [30] Equipment: Tape measure 0. p = 0.46) 19.Sadler et al. p = 0.38 Methods: Sit-up.59 (1. p = 0. p = 0.34) 83.041) 0. and T12 in prone position with max extension.93) 20.70) 31.45-1.147) 0.7%.76 Method: Devices placed on spinous process of S2.34-4.35.67 Method: Modified Schober Overall effect size (I-squared = 34%.56-2.25-3.00 (0.97-1.209) 1.28 Method: Distance from tips of the middle fingers to the ground during max forward bending with feet together and knees extended Overall effect size (I-squared = 0%.32 (0.00 (0.167) 100 Lumbar extension ROM Adams et al [29] Equipment: 3Space Isotrak device 0.13) 62.40-2. stop midway then resistance applied to the sternum.69 (0.94-1.29 (0.96 (0. Curve traced on paper then angle in degrees measured.02 (0. BMC Musculoskeletal Disorders (2017) 18:179 Page 10 of 15 Table 3 Overview of significant and nonsignificant risk factors in meta-analyses (Continued) Overall effect size (I-squared = 41.75-9.53 Method: Sitting with hips flexed and knees extended Kujala et al [35] Equipment: Tape measure 2.03) 99.367) 100 Isometric abdominal strength Biering-Sorensen et al [30] 0 Equipment: Strain gauge dynamometer 1.96.515) 1. Max force that participant could hold in that position recorded Overall effect size (I-squared = 0%.07) 8.88 (0. Van Nieuwenhuyse et al [38] Equipment: none 0.25 (0.62 Methods: Device attached to shoulders of participant and the MVC of 3 attempts of flexion in upright standing Feldman et al [31] Equipment: Hand held myometer 0.43 Method: Schober Kujala et al [35] Equipment: Tape measure 0.00 (0.92-1. p = 0.13 Method: Degrees of knee flexion in a prone position . p = 0.20 (0.37) 0.12 p = 0.160) 100 Lumbar flexion range Adams et al [29] Equipment: 3Space Isotrak device 1.81) 0.89-1.42-1.13 Method: Distance from tips of the middle fingers to the ground during max forward bending with feet together and knees extended Feldman et al [31] Equipment: Sit and reach box 1.55-1.55 Method: passive extension of lower back measured as presence or absence of pain Overall effect size (I-squared = 68. p = 0. L4.14) 22.69 Method: Sensors on sacrum and L1 spinous process measured degree change between upright standing and max extension in prone position Kujala et al [35] Equipment: Draughtsman’s flexible curve 1.602) 1.96 (0.98 Method: Modified Schober Feldman et al [31] Equipment: Tape measure 0. p = 0.73-1.06 Method: Distance from tips of the middle fingers to the ground during max forward bending with feet together and knees extended Van Nieuwenhuyse et al [38] Equipment: Tape measure 1.03.95 (0.67-1.19 (0.68 (0.28) 0.2%.23-5. p = 0.97-1.92 of motion (ROM) Method: Sensors on sacrum and L1 spinous process measured degree change between upright standing and max forward flexion sitting with legs extended Biering-Sorensen et al [30] Equipment: Tape measure 2.93 (0.12-0.55.69-1.65 (0.31-1.53) 16.34) 45.973) 100 Quadriceps flexibility Feldman et al [31] Equipment: Goniometer 1.

212) 100 MVC max voluntary contraction.389) 100 Erector spinae CSA Fortin et al [40] Equipment: 1.722) 100 Quadratus lumborum CSA Gibbons et al [32] Equipment: 1.9%. Kountouris et al [34] Equipment: MRI and imaging software 0.297) 2. Smaller degrees of knee flexion equated to tighter quadriceps Overall effect size (I-squared = 73.06 (-0.25 magnetic resonance imager Method: T2-weighted techniques at L3-4 and L5-S1 Gibbons et al [32] Equipment: 1. 3 Annotated forest plot for lumbar lordosis and LBP .5 tesla Magnetom magnetic 2. p = 0.48-0.31) 27. MRI magnetic resonance imaging Lateral flexion.823) -0. p = 0. lumbar lor- [30.00 (-0. to be prospectively associated with the development of facilitates the spine to absorb force [41] and it is per. BMC Musculoskeletal Disorders (2017) 18:179 Page 11 of 15 Table 3 Overview of significant and nonsignificant risk factors in meta-analyses (Continued) Kanchanomai et al [33] Equipment: Goniometer 1.76-2. Overall effect size (I-squared = 0%. LBP.74.55 (0. in addition to sagittal plane motion.5 tesla Magnetom magnetic 0.15 Method: Axial MR images measured at L2 and L4 levels Overall effect size (I-squared = 8%.89-9. 43].71 (1. p = 0.22 (0.24 (0. p = 0. p = 0.3 mm at the L3-4 level. p = 0.75 resonance imager Method: Slice thickness was 3 mm and gaps between the slices 0. which concurs with the results reported previously in haps due to this restriction in motion and therefore a systematic review of case control studies [44]. fulcrum is placed over the lateral epicondyle of the femur and the moving arm is aligned with the lateral midline of the fibula.86) 82.28. CSA cross sectional area.09 (-0.3 mm at the L3-4 level.03.65-0.03-2.37) 17. A previous Fig.03-10.63-7.5 Tesla Magnetom SP 4000 -0.65) 72. stiffness in the lower back that participants developed LBP As with lateral flexion of the lower back.96 (0.85 resonance imager Method: Slice thickness was 3 mm and gaps between the slices 0.40-0.87 Method: Stationary arm of device aligned with the lateral midline of the thigh.84) 37. 42. We found a reduction in lateral flexion ROM dosis is responsible for absorbing force [29].050) 1.Sadler et al.

extension ROM. It is also important to note that factors are less likely to be predictors for the development other sagittal plane parameters. and lumbar flexion ference between the degree of lumbar lordosis in those ROM were not significant. cluded in the reviews. 39].Sadler et al. these risk factors may potentially serve to prevent the The meta-analyses on a number of musculoskeletal development of LBP. and tight ham- significant association was demonstrated. could be associated with the caution and that additional research is needed before development of LBP. 37. particularly as the reference point for measuring non-significant but had no or minimal heterogeneity. measurement techniques. 4 Annotated forest plot for hamstring flexibility and LBP systematic review of retrospective articles found no dif. such as sacral slope and of LBP. lumbar lordosis [45] and it is perhaps through this mech. studies (Table 3). 31. Contrastingly. Our findings are contrary to moderate to high heterogeneity between the studies this and suggest that a reduced lumbar lordosis is an im. back muscle strength. Clinically. lumbar were found to be nonsignificant for the development of . position that is similar to those who are asymptomatic. abdominal strength. 35]. these need to be etal risk factors for the development of LBP. Advising interpreted in light of the dominance of one study in the patients of the relationship of these musculoskeletal analysis [31] and the fact that the confidence intervals are measures to LBP plus the therapy options to modify close to the point of no effect. CSA how lumbar lordosis was measured in the included stud. However. can influence the degree of lordosis niques. The conflicting findings may be explained by the discussed [29. and settings in which the dosis may change in response to LBP developing so that studies were conducted further highlighting the diverse symptomatic relief may be achieved through adopting a nature of the literature on LBP. although not reported indicate that these results should be interpreted with in the included studies. differences in demographics of study populations. as well as the small number of included studies. restriction in lateral bending ROM of the anism and subsequent stiffness in the lower back that a lumbar region. This may be due to the with and without LBP [44]. of erector spinae and quadratus lumborum were also ies. and these parameters themselves. in these meta-analyses. these risk factors can be confidently excluded as possible Restricted hamstring ROM has been linked to reduced predictors of LBP. meta-analyses on finger-tip to floor Furthermore our results may also have been affected by distance. which may have influenced the degree reported that these risk factors were significant predictors of lordosis measured in some participants within these for the development of LBP. or that the degree of lumbar lor. and may be partly explained by the inclusion of partici- portant musculoskeletal risk factor for the development pants with and without a history of LBP as previously of LBP. lumbar lordosis differed between some of the included Supporting this is that no study. the risk factors that risk factors including back muscle endurance. BMC Musculoskeletal Disorders (2017) 18:179 Page 12 of 15 Fig. Additionally. there were notable differences between the study types or participants in. The mixed populations and measurement tech- pelvic incidence. limited lumbar lordosis. quadriceps flexibility. This indicates that these studies [29. Although the string muscles can be used as predictive musculoskel- results of our meta-analysis support this.

Additional file 1: Detailed search strategy. for extraneous variables to influence the development of LBP over an extended period of time. None of the included studies stated whether partici- Acknowledgements pants developed specific or non-specific LBP. Additionally. and only include participants with no history of LBP. the short follow up time Publisher’s Note of 14 weeks in the Milgrom et al. analysis and Limitations interpretation of data. be. The majority of musculoskeletal populations. therefore influencing the effect size of risk factors mea- fidently recommended as risk factors that should be sured. while foot orth. it may also clarify Availability of data and materials if certain risk factors truly do predict the development of All of the data for this study are contained in the manuscript. has identified that the when interpreting the results. reduced lumbar lordosis the identification of risk factors which are predictive of were associated with an increased risk of developing LBP LBP from one domain challenging in heterogeneous over a 12 month period. psychological. analysis and interpretation of data. general population [49]. Castro-Mendez and colleagues [50] found that participants with LBP and excessive foot Additional files pronation were more likely to improve with the use of custom foot orthoses compared to a control intervention. and duration of LBP may provide further guidance in the management of LBP and could lead to a clearer Funding No funding was obtained for this study. (DOCX 20 kb) LBP that participants developed in the included studies. considering that additional risk factors may be have Ethics approval and consent to participate been discovered or the effect sizes of included predictor Not applicable. English. Authors’ contributions ately categorise the type and duration of LBP. Consequently. BMC Musculoskeletal Disorders (2017) 18:179 Page 13 of 15 LBP require more investigation before they can be con. adopt a standardised definition of LBP. Additional file 3: Fully annotated forest plots for non-significant meta- The secondary aims of this systematic review in. and drafting and revising of the manuscript. review and those of the individual studies is recommended Previous research [46–48]. analyses. and due to the inconsist- ent definitions of what constitutes LBP. we found that a restriction in lateral flexion differing proportions between individuals. Consent for publication cause it is not known if this would happen it is worth Not applicable. However. nor was The authors acknowledge the contribution of Jason Adams (JA) in the the duration of LBP identified. (DOCX 449 kb) cluded the identification of the type and duration of Additional file 4: Overview of risk factors measured in single studies. LBP. provide raw a homogenous population. All authors read and approved the final manuscript. future research should aim to strated that patients’ response to interventions for the measure additional lower limb musculoskeletal risk fac- treatment of LBP may be more consistent when applied to tors. variables may have differed if studies of longer dura- tions were included. The authors also suggest that regular reporting of LBP symptoms is needed to prevent recall bias and accur. cause of LBP is likely to be multifactorial with physical. back region. contributed to the analysis of data. databases and our manual search a number of add. Supporting this are the findings of a previous risk factors investigated in the literature relate to the lower study investigating interventions for LBP which demon. XJDJ contributed to the drafting and revising of the manuscript. data so results can be meaningfully pooled between stud- oses have been shown to have little effect on LBP in the ies. SS contributed to the conception and design of the review. Likewise. Identification of the type quality appraisal of included articles. and drafting and revising of the manuscript. (DOCX 16 kb) These findings suggest that musculoskeletal risk factors Additional file 2: List of full text articles excluded with reasons. This makes and hamstring ROM. Consideration of the limitations of this systematic measured in clinical practice. . environmental. and drafting and revising of the itional sources we only included articles published in manuscript. MS contributed to the conception and design of the review. the additional files. or the individual studies included in this systematic review. [37] study may have Springer Nature remains neutral with regard to jurisdictional claims in not been long enough for participants to develop LBP published maps and institutional affiliations. as well as. The authors decided to limit the maximum follow-up period to 12 months because of the potential Competing interests The authors declare that they have no competing interests. may have a greater contribution to the development of (DOCX 27 kb) LBP in certain subgroups. For example. AH This systematic review is not without limitations. VC contributed to the conception and design of the review. analysis and interpretation of data.Sadler et al. and application of statistical though our electronic search encompassed a range of techniques. Al. and demographic factors Conclusion potentially contributing to the development of LBP in In summary. definition of LBP.

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