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Screening initial entry training trainees for postural faults and low back or hip pain.

BACKGROUND

Nonspecific lower back pain and lower extremity injuries without known event are reported frequently during Army Basic Combat Training (BCT) and Advanced Individual Training (AIT). Postural faults and related muscular endurance are common deficits observed upon physical therapy examination for lower back pain.

Swayback posture is a simple postural fault to identify using gross landmarks of the lateral malleolus, greater trochanter of the femur, and the greater tubercle of the humerus. Exaggerated shifting of weight over one hip is also observable with short term assessment. Both postural faults may be considered a compensation for reduced postural muscle endurance or use and can shift stress to the hip joint or muscles and ligaments of the spine.

When assessed for posture using a plumb line, swayback posture is categorized by the hips and ankle bones being in front of the plumb line, and the upper back trying to counterbalance things by being further behind the line than usual. Kendall has referenced swayback as a primary postural fault. (1) Sahrmann has noted weakness in posterior hip muscles and anterior abdominal muscles to contribute to this postural fault. (2) Reeve et al has found that transverse abdominus thickness and activity is significantly different in erect upright posture sitting or standing in comparison to slumped sitting or swayback posture. (3) Pezolato et al (4) found that the multifidus muscles demonstrated greater fatty infiltrate in subjects with swayback posture, with or without symptoms, in comparison to a control group. Fatty infiltrate in muscle tissue is associated with muscle atrophy.

No study measuring the frequency of postural faults in military trainees was identified on literature review. Literature review did locate 2 studies on nonmilitary populations of similar age. Norris et al observed 26 university students ranging in age from 18 to 28 years in an exercise course. Fifteen of the 26 subjects (58%) demonstrated swayback posture but only six of those 15 had a complaint of low back pain. (5) Abdolvahabi et al observed 70 female students ranging in age from 17 to 26 years without pain complaints to assess the effect of swayback on other joints, categorizing 35% of the subjects as having swayback posture. (6)

In clinical practice, the author has observed a high frequency of military patients with hip or back pain who present with swayback posture, most of whom were not aware of the postural fault. The frequency of subjects who have swayback posture without back or hip pain has not been established on a larger sample.

This study was a cross-sectional survey of the incidence of swayback or exaggerated uneven weight distribution posture and the presence of hip or lower back pain. Male and female military trainees were recruited during in-processing prior to initiating AIT. The primary research objective was to measure the frequency of subjects with upright, unilateral weight shift posture, or swayback posture and correlation with hip or lower back pain. The secondary research objective was to provide military training installation personnel feedback on the need for postural education and training as part of integration into military training.

Research hypotheses were that subjects with grossly identified unilateral shift or swayback posture will have an increased frequency of low back pain or hip pain history, and that a significant number of subjects without symptoms will be unaware of postural faults.

METHODS

Over a 5-week period, inprocessing AIT trainees (N = 1,904) at the installation inprocessing station were informed of the study's process and intent after the subjects had completed administrative forms. The potential subjects were informed that the study would remain anonymous and that consent would be limited to verbal consent due to the limitation in time available for the subjects during inprocessing and prior to starting training. Inclusion and exclusion criteria were strictly based on the subject's agreement to be observed for posture and to complete the questionnaire. The number of subjects verbally declining to participate in the study was not recorded.

Approximately 100 subjects per class were observed after individually providing verbal consent (5 groups totalling 500 subjects) while standing in line for administrative processing. Fourteen unanswered questionnaires were submitted. The final group required measurement of 138 subjects to achieve the desired 500 participants.

Each subject was determined to have upright posture if observation from their side demonstrated a straight line from the ankle to the pelvis/femur and to the shoulder, and observation from the front or behind demonstrated a grossly vertical line with weight distributed between both feet. Subjects were determined to have a postural fault if the pelvis/head of the femur was observed to be forward of the line from shoulder to ankle or the subject's weight was shifted over to a side. Subjects were given a stripsized questionnaire with bold face type if a swayback fault (bad) was identified, or an underlined questionnaire (upright) if no gross fault was observed. Subjects were not informed of the different strip significance or given any verbal feedback of the author's conclusion.

No demographic data, including name, age, gender, height, or weight, were requested. Multiple subjects inquired about whether to submit their name and were instructed not to include it. This was intentional to avoid concerns for identification and to provide the most honest feedback. Questionnaires were placed in a locked slot box and were not viewed by the author until all forms for that day were collected. Analysis was performed for correlation between postural fault presence and history of back pain, hip pain, and the percentage of subjects who are aware of the presence of a postural fault.

RESULTS

Five hundred total subjects were observed and also completed the questionnaire. Two hundred ninety-eight subjects demonstrated upright posture (59.6%) and 202 (40.4%) demonstrated a postural fault. Three hundred fifteen subjects had no history of hip or lower back pain (63% overall, 65.4% with upright posture, 59.4% with postural fault), 53 subjects reported having lower back and hip pain (10.6%), 99 subjects reported having only lower back pain (19.8%), and 33 subjects reported having only hip pain (6.6%). Total subjects with lower back pain were 152 (30.4%) and hip pain were 86 (17.2%). Thirty-two subjects had bilateral hip pain, 21 subjects had left hip pain, and 33 subjects had right hip pain.

Two hundred sixty of 298 subjects observed with proper posture believed they had proper posture (87.3%); 38 subjects with observed proper posture believed that they had poor posture (12.7%).

One hundred seventy eight of 202 subjects observed with postural faults believed they had proper posture (88%); 24 subjects with observed postural faults believed that they had poor posture (12%).

Hip pain was reported by 44 subjects observed with upright posture (14.7%) and 42 subjects with postural faults (21.2%).

Lower back pain was reported by 85 subjects observed with upright posture (28.5%) and 67 subjects with postural faults (33.2%).

A comparison of frequencies for lower back pain based on observation and patient reports for posture found that lower back pain was present in 23.1% (60 of 260) subjects who demonstrated and reported proper posture, 28.1% (50 of 178) subjects who demonstrated postural faults but reported proper posture, 62.5% (15 of 24) subjects who demonstrated postural faults and reported poor posture, and 71.1% (27 of 38) subjects who demonstrated proper posture but reported poor posture. The distributions are presented in Figures 1 through 4.

Analysis of frequency for hip pain based on observation and patient report for posture found that lower back pain was present in 10.8% (28 of 260) of subjects who demonstrated and reported proper posture, 18.5% (33 of 178) of subjects who demonstrated postural faults but reported proper posture, 37.5% (9 of 24) of subjects who demonstrated postural faults and reported poor posture, and 42.1% (16 of 38) of subjects who demonstrated proper posture but reported poor posture. The data is presented in the Table.

DATA ANALYSIS

Chi-square measurements were completed for the ratios of the subjects with and without postural faults who present with hip pain history, subjects with postural faults who present with back pain history, and ratio of subjects matching perception of posture.

Values for Pearson [chi square] did not reach significant levels for hip pain (3.071, minimum 34.74) or lower back pain (3.622, minimum 8.48), but did reach significance for perception of posture (278.695, minimum 87.26). Likelihood ratios for poor posture and hip pain (3.03) and lower back pain (3.56) were not strong. Perception of posture had a likelihood ratio of 309.13.

COMMENT

Findings from this study suggest that there is no statistical correlation between observed posture quality and presence or absence of lower back pain or hip pain in this population. The only correlation supported by [chi square] ratios relates to observed posture and perceived posture.

The percentage of subjects with postural faults was comparable to the finding of 35 % by Abdolvahabi et al (6) and below the finding of 58% by Norris et al. (5) The percentage reporting back pain was closer to the Norris et al finding (33.2% vs 40% of subjects with swayback). (5)

At the time of this study, the author was participating in an injury prevention program with the single objective of early injury identification. All Soldiers arriving from BCT were given an intake form which included inquiries about any prior injury at BCT and present requests for medical care. More meaningful to military training and injury prevention is the observed discrepancy between prior injury or pain complaints in an anonymous survey and these intake screening questionnaires. This finding was not an initial objective and was not anticipated to the observed magnitude. Initial Entry Training Soldiers often delay reporting injury either during BCT or upon arrival at AIT due to concerns of having a delay in training while receiving medical treatment. During the 5 week study period, only 10 Soldiers reported hip pain and 7 Soldiers reported back pain when given the opportunity to seek care prior to starting advanced training. If all 17 of the Soldiers who requested care were included in the surveyed population, there would still be a discrepancy between the rate of direct reporting (3.4%) and the survey results (37%).

Due to the study's anonymity and sample percentage, the investigator is not able to follow-up to determine the number of Soldiers who requested or required medical care during training or at BCT. The other recognized limitation in this finding is the potentially high percentage of reported lower back pain that has been resolved or reported when present for only a few days after more vigorous training.

Although the percentage of subjects who reported having poor posture was only 12.4%, the percentage within that subgroup that reported having a history of hip or back pain was 76% (47 of 62), which was higher than the percentage of subjects with hip or back pain observed with poor posture but reported proper posture (36%), or observed with good posture (24.5%). As a screening process, it suggests limiting future application for larger populations to a written survey. This conclusion will require validation through application on an intake survey that is not anonymous.

Limitations of the study include lack of clarification as to whether the subjects had current back or hip pain and the duration of lower back or hip pain. There was uncertainty if subjects reported short duration soreness after vigorous work (wearing body armor or road march in BCT) as lower back pain, and there was a lack of demographic information including differentiation by gender. Most Soldiers completing initial training are aged 21 years or younger, but comparisons of groups cannot be provided and would require modification of the study and the consent.

The Soldiers participating in the study were typically standing in place for less than 2 to 3 minutes; therefore, postural faults that may develop after 15 to 20 minutes were not observed. Soldiers who have lower back and hip pain may also have concluded that they have poor posture based on symptoms history, but this could not be verified. Due to the limitations in time available and level of consent, the author also consciously removed an axial compression test used in clinical practice to verify postural faults as functional or meaningful.

Follow-up studies should include a study of the rate of injury disclosure through inclusion of postural self-assessment on the intake survey and associated follow-up to assess for hip and lower back pain, and a study to validate the magnitude of swayback that is meaningful.

CONCLUSIONS

Observational screening of posture for Soldiers in Initial Entry Training does not effectively identify Soldiers with a history of lower back or hip pain. Written questionnaires including focus on posture may offer better feedback of a population but would require reevaluation without anonymity.

A significant percentage (40%) of Soldiers in Initial Entry Training demonstrate postural faults, most of which are not recognized by the Soldiers.

ACKNOWLEDGEMENTS

This study was part of the Injury Prevention Program jointly sponsored by the Army Training and Doctrine Command and the Army Medical Command. It was conducted in compliance with a protocol approved by the Walter Reed National Military Medical Center Institutional Review Board.

REFERENCES

(1.) Kendall FP, McCreary EK. Muscles: Testing and Function. Baltimore, MD: Willaims & Wilkins; 1983.

(2.) Sahrmann S. Diagnosis and Treatment of Movement Impairment Syndromes. St Louis, MO: Mos by, Inc; 2002.

(3.) Reeve A, Dilley A. Effects of posture on the thickness of transversus abdominis in pain-free subjects. Man Ther. 2009;14(6):679-684.

(4.) Pezolato A, de Vasconcelos EE, Defino HL, Nogueira-Barbosa MH. Fat infiltration in the lumbar multifidus and erector spinae muscles in subjects with sway-back posture. Eur Spine J. 2012;21(11):2158-2164.

(5.) Norris CM, Berry S. Occurrence of common lumbar posture types in the student sporting population: an initial investigation. Sports Exerc Inj. 1998;4:15-18.

(6.) Abdolvahabi Z, Naeini SS, Kallashi M, Shabani A, Rahmati H. The effect of sway back abnormality on body segments follow-up changes. Ann Biol Res. 2012;3(1):140-148.

MAJ John R. Lane, SP, USA

When this study was conducted, MAJ Lane was working in the Injury Protection Program of the Musculoskeletal Action Team, Kenner Army Health Clinic, Fort Lee, Virginia. He is currently Chief, Physical Therapy, 168th Multifunctional Medical Battalion, in the Republic of Korea.
Distribution of observed and reported postures,
1 with related reported pain symptoms.

Posture Category                      Total   Low Back   Hip
                                                Pain     Pain

Upright observed, upright reported     260       60       28
Upright observed, fault reported       38        27       16
Fault observed, upright reported       178       50       33
Fault observed, fault reported         24        15       9

Figure 1. Pain symptom distribution reported by all
participants in the study (N = 500).

No Symptoms     63%
Low back pain   20%
Hip pain only   6%
Hip and low     11%
  back pain

Note: Table made from pie chart.

Figure 2. Pain distribution reported by participants
who incorrectly believed that they had proper posture
(n = 178).

No Symptoms     64%
Low back pain   17%
Hip pain only   8%
Hip and low     11%
  back pain

Note: Table made from pie chart.

Figure 3. Pain symptom distribution reported by
participants who correctly believed that they had
proper posture (n = 260).

No Symptoms     70%
Low back pain   18%
Hip pain only   5%
Hip and low     7%
  back pain

Note: Table made from pie chart.

Figure 4. Pain symptom distribution reported by
participants who believed that they had poor posture
(n = 62), although 38 of them were observed to
have proper posture.

No Symptoms     25%
Low back pain   34%
Hip pain only   7%
Hip and low     34%
  back pain

Note: Table made from pie chart.
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Author:Lane, John R.
Publication:U.S. Army Medical Department Journal
Article Type:Report
Date:Apr 1, 2014
Words:2614
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