Intervertebral disc degeneration is a major cause of low back pain. Despite its long history and large socio-economical impact in western societies, the initiation and progress of disc degeneration is not well understood and a generic disease model is lacking. In literature, mechanics and biology have both been implicated as the predominant inductive cause; here we argue that they are interconnected and amplify each other. This view is supported by the growing awareness that cellular physiology is strongly affected by mechanical loading. We propose a vicious circle of mechanical overloading, catabolic cell response, and degeneration of the water-binding extracellular matrix. Rather than simplifying the disease, the model illustrates the complexity of disc degeneration, because all factors are interrelated. It may however solve some of the controversy in the field, because the vicious circle can be entered at any point, eventually leading to the same pathology. The proposed disease model explains the comparable efficacy of very different animal models of disc degeneration, but also helps to consider the consequences of therapeutic interventions, either at the cellular, material or mechanical level.

IntroductionPregnancy-related lumbopelvic pain has puzzled medicine for a long time. More than 2,000 years ago, Hippocrates (c. 460-c. 377 B.C.) theorised that an irreversible relaxation and widening of the pelvis occurs with the first pregnancy [50], the resultant instability of the sacroiliac joints leading to symptomatic inflammation [94].Recent literature suggests that around half of all pregnant women incur lumbopelvic pain [7, 31, 35, 62,

During human walking, the centre of mass (CoM) is outside the base of support for most of the time, which poses a challenge to stabilizing the gait pattern. Nevertheless, most of us are able to walk without substantial problems. In this review, we aim to provide an integrative overview of how humans cope with an underactuated gait pattern. A central idea that emerges from the literature is that foot placement is crucial in maintaining a stable gait pattern. In this review, we explore this idea; we first describe mechanical models and concepts that have been used to predict how foot placement can be used to control gait stability. These concepts, such as for instance the extrapolated CoM concept, the foot placement estimator concept and the capture point concept, provide explicit predictions on where to place the foot relative to the body at each step, such that gait is stabilized. Next, we describe empirical findings on foot placement during human gait in unperturbed and perturbed conditions. We conclude that humans show behaviour that is largely in accordance with the aforementioned concepts, with foot placement being actively coordinated to body CoM kinematics during the preceding step. In this section, we also address the requirements for such control in terms of the sensory information and the motor strategies that can implement such control, as well as the parts of the central nervous system that may be involved. We show that visual, vestibular and proprioceptive information contribute to estimation of the state of the CoM. Foot placement is adjusted to variations in CoM state mainly by modulation of hip abductor muscle activity during the swing phase of gait, and this process appears to be under spinal and supraspinal, including cortical, control. We conclude with a description of how control of foot placement can be impaired in humans, using ageing as a primary example and with some reference to pathology, and we address alternative strategies available to stabilize gait, which include modulation of ankle moments in the stance leg and changes in body angular momentum, such as rapid trunk tilts. Finally, for future research, we believe that especially the integration of consideration of environmental constraints on foot placement with balance control deserves attention.

The concepts of comfort and discomfort in sitting are under debate. There is no widely accepted definition, although it is beyond dispute that comfort and discomfort are feelings or emotions that are subjective in nature. Yet, beside several subjective methodologies, several objective methods (e.g. posture analysis, pressure measurements, electromyography (EMG) are in use to assess sitting comfort or discomfort. In the current paper a theoretical framework is presented, in which comfort and discomfort were defined and the hypothetical associations with underlying factors were indicated. Next, the literature was reviewed to determine the relationships between objective measures and subjective ratings of comfort and discomfort. Twenty-one studies were found in which simultaneous measures of an objective parameter and a subjective rating of comfort or discomfort were obtained. Pressure distribution appears to be the objective measure with the most clear association with the subjective ratings. For other variables, regarding spinal profile or muscle activity for instance, the reported associations are less clear and usually not statistically significant.

Study Design. A comparative study of trunk muscle recruitment patterns in healthy control subjects and patients with chronic low back pain was conducted. Objective. To assess trunk muscle recruitment in patients with low back pain. Summary of Background Data. Conflicting evidence has been reported on the level and pattern of trunk muscle recruitment in patients with low back pain. The disparities can be explained partly by methodologic differences. It was hypothesized that trunk muscle recruitment patterns may be altered in patients with low back pain to compensate for reduced spinal stability. Methods. For this study, 16 patients with low back pain and 16 matched control subjects performed slow trunk motions about the neutral posture and isometric ramp contractions while seated upright. Ratios of electromyographic amplitudes and estimated moment contributions of antagonist over agonist muscles and of segmentally inserting muscles over muscles inserting on the thorax and pelvis only were calculated. In addition, model simulations were performed to assess the effect of changes in muscle recruitment on spinal stability. Results. The ratios of antagonist over agonist, and of lumbar over thoracic erector spinae electromyographic amplitude and estimated moment contributions were greater in the patients than in the control subjects. The simulation model predicted that these changes would effectively increase spinal stability. Conclusions. Trunk muscle recruitment patterns in patients with low back pain are different from those in healthy control subjects. The differences are likely to be functional with respect to enhancement of spinal stability in the patients.

Tripping over an obstacle can result in a fall when the forward angular momentum, obtained from impact with the obstacle, is not arrested. Angular momentum can be restrained by proper placement of the recovery limb, anteriorly of the body, but possibly also by a reaction in the contralateral support limb during push-off. The purpose of this study was to quantify the extent to which the support limb contributes to recovery after tripping by providing time and clearance for proper positioning of the recovery limb, and by restraining the angular momentum of the body during push-off. Twelve young adults were repeatedly tripped over an obstacle during mid-swing, while walking over a platform. Kinematics and ground reaction forces at the support limb were measured. Quantification of the angular momentum was based on calculation of the external moment, which equals the rate of change in the angular momentum of the body. Results showed that all subjects acquired a similar increase in angular momentum during foot-obstacle contact, on average 11.4 kg m2s(-1). In all subjects, the support limb played a role in recovery after tripping by providing time and clearance for proper positioning of the recovery limb, as indicated by body elevation (6%) and the increased forward pelvis displacement over recovery stride (43%). Almost all subjects were also able to restrain the forward angular momentum of the body during push-off by the support limb. Less angular momentum remained to be further accomplished by the recovery limb. Reductions in the quality of the support limb responses may be among the factors that increase the risk of falling in the elderly.

In comparison with healthy participants, the gait of patients with low back pain was characterized by a more rigid, less flexible pelvis-thorax coordination in the absence of significant differences in the kinematics of the component rotations. This result suggests that coordination measures are more adequate in assessing quality of walking in patients with low back pain than are kinematic measures pertaining to the individual segment rotations, and that conservative therapy should use methods aimed at improving intersegmental coordination.

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