Asymmetrical movements of the lumbopelvic region: Is this a potential mechanism for low back pain in people with lower limb amputation? q Hemakumar Devan a,⇑ , Paul Hendrick b , Daniel Cury Ribeiro a , Leigh A Hale a , Allan Carman c a Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, 325 Great King Street, Dunedin 9016, New Zealand b Division of Physiotherapy Education, University of Nottingham, Nottingham, United Kingdom c School of Sport & Recreation, Auckland University of Technology, Auckland, New Zealand article info Article history: Received 4 August 2013 Accepted 10 November 2013 abstract Low back pain (LBP) is a major secondary disabling condition following lower limb amputation including persons with above-knee and below-knee amputation. Whilst the increasing prevalence of this musculo- skeletal problem in people with lower limb amputation is well recognised, the mechanisms of LBP in this population have been poorly explored. Asymmetrical movements and loading patterns have been found in persons following lower limb amputation and linked to the high prevalence of LBP in this population. However, some argue that such asymmetries are part of the ‘normal’ adaptive process following lower limb amputation. We hypothesise that there is potential for some of the kinematic and kinetic adapta- tions in the lumbopelvic and trunk region to be ‘mal-adaptive’, potentially acting as a contributing factor for the onset or maintenance of LBP symptoms in this population. Evidence for movement and muscle asymmetries around the lumbopelvic and lower limb region provides some support for an association between LBP and movement asymmetry in the general population. It is therefore reasonable to hypoth- esise that movement asymmetries will demonstrate an association with LBP in lower limb amputee pop- ulations. Previous studies investigating movement and loading patterns within this population have focused mainly on gait analysis. Therefore, there is a need for further research to investigate the presence and potential association of asymmetrical movement patterns of the lumbopelvic region with LBP in a range of specific functional tasks. Results of such studies will identify the asymmetrical movement patterns and functional tasks associated with LBP in this population. Furthermore, it will inform future case-control and longitudinal studies to specifically investigate the putative links for such asymmetrical movement patterns as risk factors to LBP in this population. Ó 2013 Elsevier Ltd. All rights reserved. Introduction Prevalence of secondary musculoskeletal disorders is common in persons with lower limb amputation, including persons with above-knee (AKA) and below-knee amputation (BKA) [1]. In partic- ular, non-specific low back pain (NSLBP) is a major secondary impairment with 1-month prevalence ranging between 50% and 80% [2–4]. LBP was reported as ‘‘more bothersome’’ than other common comorbid conditions such as phantom pain and resid- ual-limb pain [2]. In a survey of people with lower limb amputa- tion (n = 255), 52% of respondents rated their LBP as ‘‘persistent and bothersome’’ [5]. In another study, higher levels of self- reported LBP (pain intensity 7.09 ± 1.64) had significantly greater (p < 0.05) interference on daily physical activities than that of phantom pain and general body pain [6]. These results contribute to the growing body of evidence suggesting the chronicity and the impact of LBP on physical functioning in people with lower limb amputation. In the general population, the risk factors for LBP are multifac- torial and are broadly classified into physical (biomechanical), personal, and psycho-social risk factors [7]. Physical risk-factors include heavy physical work, awkward dynamic postures, and lifting [7]. However, a recent review [8] contradicts the results of previous reviews [7,9] reporting limited evidence for a causal rela- tionship for physical factors, such as lifting and awkward postures, and LBP. Other authors argue that the repetitive nature of physical tasks may result in cumulative loading of the lumbopelvic spine, potentially increasing the risk of LBP [10,11]. Although psycho- social risk factors are not predictive of onset of first episode of LBP [12], factors such as anxiety, depression, poor coping strate- gies, fear avoidance, high psychological demands at work, and high job dissatisfaction appear to increase the risk of developing chronic LBP [13,14]. Personal risk-factors for LBP include younger age, smoking, and a high body mass index [7]. 0306-9877/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.mehy.2013.11.012 q This study was supported by grants from the New Zealand Artificial Limb Services (NZALS – A national body providing artificial limb services for people with amputation). ⇑ Corresponding author. Tel.: +64 (3) 479 5422. E-mail address: hemakumar.devan@gmail.com (H. Devan). Medical Hypotheses 82 (2014) 77–85 Contents lists available at ScienceDirect Medical Hypotheses journal homepage: www.elsevier.com/locate/mehy