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Original Investigation |

Lean Body Mass and Body Fat Distribution in Participants With Chronic Low Back Pain FREE

Yoshitaka Toda, MD; Neil Segal, MD; Tamami Toda; Tadanobu Morimoto, MD; Ryokei Ogawa, MD
[+] Author Affiliations

From the Toda Orthopedic Rheumatology Clinic, Suita (Dr Toda and Ms Toda), and the Department of Orthopedic Surgery, Kansai Medical University, Moriguchi (Drs Toda, Morimoto, and Ogawa), Osaka, Japan; and Vanderbilt University Medical School, Nashville, Tenn (Dr Segal).


Arch Intern Med. 2000;160(21):3265-3269. doi:10.1001/archinte.160.21.3265.
Text Size: A A A
Published online

Background  Loss of muscle mass and central obesity progress with aging, but the effect of muscle loss on chronic low back pain has not been precisely evaluated.

Methods  Three hundred thirty Japanese persons aged 45 to 69 years, with a complaint of low back pain for longer than 3 months (n = 203) and age- and sex-matched healthy control subjects (n = 127), were enrolled in this study. Participants with chronic low back pain were classified into the following groups: (1%) women with a positive straight leg raise test result, (2) women with a negative straight leg raise test result, (3) men with a positive straight leg raise test result, and (4) men with a negative straight leg raise test result. Controls were classified by sex into a female and a male group. Anthropometric data, consisting of body mass index, percentage body fat, waist-hip ratio, and lean body mass of the upper extremities, trunk, and lower extremities divided by body weight, were measured in participants with low back pain, and the results were compared with those of controls.

Results  The waist-hip ratio in women with a negative straight leg raise test result was significantly higher than those in the female control group (P<.001) and in the women with a positive straight leg raise test result (P = .04). The lean body mass of the trunk and lower extremities divided by body weight of women with a negative straight leg raise test result was significantly lower than that of female controls (P = .03 for the trunk and P<.001 for the lower extremities). However, no significant differences were detected between the female negative straight leg raise test result group and the female control group for lean body mass of the upper extremities divided by body weight or body mass index. There were no significant differences in anthropometric data between the male test and control groups or between the female positive straight leg raise test result group and the female control group.

Conclusion  Trunk and lower extremity loss of muscle mass and central obesity may be risk factors for chronic low back pain without a positive straight leg raise test result in women aged 45 to 69 years.

Figures in this Article

CHANGES IN body composition are known to occur during aging. In particular, a decrease in lean body mass and an increase in fat are characteristic of the aging process.1 The consequences of these changes in lean body mass may include decreased muscle mass, muscle strength, and physical activity.

Low back pain is one of the most prevalent medical disorders. It is estimated that 80% of all people will experience at least one episode of low back pain in their lifetime.2 Andersson3 described the prognosis for patients with low back pain as generally excellent, with 90% or greater recovery in 3 months. However, for individuals who do not recover within this time, the recovery process is slow, and they can be classified as patients with chronic low back pain.3

It is generally believed that there is a relation between obesity and low back pain. However, scientific evidence of this relation remains unclear.47 Recently, Han et al8 reported that a high waist-hip ratio (WHR), indicating a central obesity pattern, was significantly associated with chronic low back pain in women but not in men. In the study by Lee et al,9 the total trunk and lower extremity strength was significantly lower in the patients with low back pain than in the control group. This was attributed to generalized loss of muscle mass in patients with low back pain.9 Garzillo and Garzillo10 suggested that future studies evaluating the relation between obesity and low back pain stratify patients with low back pain into categories based on physical findings. It seems likely that sex, lean body mass, body fat distribution, and physical findings are involved in the relation between obesity and chronic low back pain.

The technique of bioelectrical impedance analysis has been shown to be a convenient, valid approach for estimating body composition. Recently, the segmental bioelectrical impedance analysis method using 8 tactile electrodes has been evaluated for measuring the distribution of body water in the trunk and upper and lower extremities.11 Segmental lean body mass can be estimated from the distribution of body water.12 In this study, the segmental bioelectrical impedance method was used to measure body mass index (BMI), percentage body fat, lean body mass of the trunk and upper and lower extremities divided by body weight, and WHR in participants with chronic low back pain, and the results were compared with those for age- and sex-matched healthy Japanese controls.

PARTICIPANTS

In this study, Japanese participants, aged 45 to 69 years, with chronic low back pain were classified into the following groups: (1) women with a positive straight leg raise test result, (2) women with a negative straight leg raise test result, (3) men with a positive straight leg raise test result, and (4) men with a negative straight leg raise test result.

Subjects were defined as having chronic low back pain if either the duration of the current episode of pain was longer than 3 months or they presented with a recurrent history of disabling low back pain (causing absence from work or significant modification of activities of daily living).3,13 Two hundred three new outpatients with chronic low back pain, aged 45 to 69 years (mean age, 59.7 years; SD, 8.7 years), visiting the Toda Orthopedic Rheumatology Clinic, Osaka, Japan, in 1999 were enrolled in this study. Sciatic pain was defined as a positive straight leg raise test result.

Control participants, recruited from a community senior center, were defined as individuals without low back pain who denied having any problem with their lower back within 10 years. One hundred twenty-seven independently living, medically stable participants, aged 45 to 69 years (mean age, 57.6 years; SD, 8.7 years), were self-selected into the study. The control group was subdivided by sex into a female and a male group.

In the chronic low back pain and control groups, no participants had a history suggestive of congenital muscle, cardiovascular, cerebrovascular, or neurologic disease, and none had sustained a leg or an arm injury within the previous 10 years that had required immobilization of a joint for more than 1 week.

MEASUREMENTS

Body composition measurements and WHRs were obtained by segmental bioelectrical impedance using 8 tactile electrodes, according to the manufacturer's instructions (In Body 2.0; Biospace, Seoul, Korea). Participants stood barefoot on a platform with electrodes attached to their hands and feet. Thus, a pair of electrodes were attached to the surface of each hand and foot at the thumb, palm, fingers, ball of the foot, and heel. These electrodes were connected to current and voltage terminals from an impedance meter via electronic on-off switches, which were regulated by a microprocessor. The body was measured in 5 segments: right upper extremity, left upper extremity, trunk, right lower extremity, and left lower extremity. To measure the resistance of the right upper extremity segment, current terminals were connected to the right palm electrode and the right ball of the foot electrode, and voltage terminals were connected to the right thumb electrode and the left thumb electrode. While the current passed through R1, the resistance of the right upper extremity segment, the resistance of the trunk segment, the resistance of the right lower extremity segment, and R3, a different voltage was measured across R2, the resistance of the right upper extremity segment, and the resistance of the left upper extremity segment. In this way, only the voltage drop occurring in the right upper extremity was measured, where current pathway and voltage detection circuits were overlapped (Figure 1).14 By regulating these switches in the appropriate on or off position, a target segment could be measured selectively.

Place holder to copy figure label and caption

Body composition measurements. RRU indicates resistance of the right upper extremity segment; RLU, resistance of the left upper extremity segment; RT, resistance of the trunk segment; A, circumference of waist; B, circumference of hip; RRL, resistance of the right lower extremity segment; RLL, resistance of the left lower extremity segment; E1, right palm electrode; E2, right thumb electrode; E3, left palm electrode; E4, left thumb electrode; E5, right ball of the foot electrode; E6, right heel of the foot electrode; E7, left ball of the foot electrode; E8, left heel of the foot electrode; R1, thumb; R2, palm; R3, heel; and R4, front foot.

Graphic Jump Location

The chemical composition of lean body mass is assumed to be relatively constant, with a density of 1.1 kg/m3 at 37°C and a water content of 73%.12 Thus, the lean body mass of the upper extremities, trunk, and lower extremities was calculated by multiplying the values for water volumes of the upper extremities (a sum of right and left), trunk, and lower extremities (a sum of right and left) by 1.37. Each segmental lean body mass was divided by body weight to estimate segmental lean body mass per body weight.

Height was measured to the nearest 1 cm using a stadiometer. Weight was measured with subjects standing erect, wearing only underwear and a robe, to the nearest 0.1 kg. The BMI was calculated as weight in kilograms divided by the square of height in meters.

STATISTICAL ANALYSIS

Differences in BMI, percentage body fat, lean body mass of the upper extremities, trunk, and lower extremities divided by body weight, and WHR between the chronic low back pain and control groups were tested using nonparametric analysis by the Kruskal-Wallis method. Statistical significance levels were considered to be P<.05.

The chronic low back pain and control groups were well matched for age, height, and weight. Disease duration did not significantly differ among male or female groups regardless of the results of the straight leg raise test (P = .19 and P = .88, respectively%) (Table 1). Comparison of anthropometric data demonstrated no significant differences between the male control, male with a positive straight leg raise test result, and male with a negative straight leg raise test result groups (Table 2).

Table Graphic Jump LocationTable 1. Characteristics of the Chronic Low Back Pain and Control Groups*
Table Graphic Jump LocationTable 2. Anthropometric Data of the Male Groups*

Comparison of anthropometric data for the female control, female with a positive straight leg raise test result, and female with a negative straight leg raise test result groups was presented in Table 3. Percentage body fat was significantly greater in the female with a negative straight leg raise test result group than in the female control group. The average BMI did not significantly differ among the 3 groups. The WHR in the female with a negative straight leg raise test result group was significantly higher than those of the female control group and the female with a positive straight leg raise test result group.

Table Graphic Jump LocationTable 3. Anthropometric Data of the Female Groups*

The lean body mass of the trunk and lower extremities divided by body weight measurements for women with a negative straight leg raise test result were significantly lower than those for the female controls. However, no significant differences in lean body mass of the upper extremities divided by body weight were observed between the female with a negative straight leg raise test result group and the female control group (P = .65). There were no significant differences in any anthropometric data between the female with a positive straight leg raise test result group and the female control group.

To our knowledge, this is the first study that has examined segmental body composition in patients with chronic low back pain. The results of this study demonstrate that women, aged 45 to 69 years, with chronic low back pain and a negative straight leg raise test result are characterized by an increased percentage of body fat and WHR and a reduced lean body mass of the trunk and lower extremities divided by body weight compared with a matched control cohort. However, the BMI and the lean body mass of the upper extremities divided by body weight do not appear to be independent risk factors for chronic low back pain with a negative straight leg raise test result in this cohort. This suggests that loss of muscle mass of the trunk and lower extremities and central obesity may be risk factors for chronic low back pain without sciatic pain in women in this age group.

Waist-hip ratio was shown to be significantly greater for women with low back pain with a negative straight leg raise test result than for participants in the control and positive straight leg raise test result groups. Waist-hip ratio is one of the most commonly used anthropometric measures to indicate a central obesity pattern.15 Past research1518 has consistently demonstrated that adipose tissue distribution, rather than absolute total fat, is associated with an increased risk of diabetes, hypertension, lipemia, and coronary artery disease. Thus, it is important to evaluate whether women, aged 45 to 69 years, with central obesity also possess a higher risk of degenerative disorders such as low back pain.

For BMI, there was no significant difference between participants with low back pain and healthy controls in either sex group. Although BMI is commonly used as a measure of obesity, it does not differentiate fat mass from lean body mass.10 Leboeuf-Yde et al19 reported that a positive association between BMI and low back pain did not hold in studies of monozygotic twins who were dissimilar in body weight classification. This suggests that assessment of BMI alone will not reveal the relation between obesity and low back pain. Analysis of the results of our study confirms these findings, in that the distribution of lean body mass and body fat was shown to be more closely associated with a risk of chronic low back pain than BMI.

In this study, the values for lean body mass of the trunk and lower extremities divided by body weight were significantly lower in women with low back pain with a negative straight leg raise test result than in the control cohort. It is believed that strengthening and stretching exercises are more clinically effective than traditional management of patients with low back pain.20 Thus, considering the relation between reduced segmental lean body mass and low back pain previously described, it is plausible that increasing the lean body mass of the trunk and lower extremities using exercises may improve symptoms of women with low back pain. As follow-up to this characterization of anthropometric risk factors, it will be important to study this therapeutic relation.

Chronic low back pain with a positive straight leg raise test result in male and female subjects was not significantly related to any anthropometric data, compared with age- and sex-matched controls. As indicated previously, in previous epidemiological studies,47 scientific evidence of the relation between obesity and low back pain remained unclear. Therefore, it was incumbent on us to evaluate the relation between obesity and low back pain, splitting the population of patients with low back pain by presence or absence of a positive straight leg raise test result. We believe that this study provides some useful information, and deems further characterization of the relation between obesity and low back pain, using the straight leg raise test results as grouping criteria.

In male participants, no significant relation was observed between chronic low back pain and the distribution of lean body mass or body fat content. There have been reports21 that physical demands, age, and family history, but not obesity, are risk factors for low back pain in Japanese men. Thus, chronic low back pain in men seems to better correlate with factors other than obesity. In this study, the number of female participants was greater than the number of male participants. In Japan, chronic low back pain is more prevalent in women than in men, and a matched number of participants was recruited for the control group. Therefore, a further study is indicated in which many male subjects are enrolled.

A sedentary lifestyle and consumption of food high in fat has become widespread, particularly among urban populations. This lifestyle will likely lead to a reduction in lower extremity and trunk lean body mass and an increase in body fat. This case-control study was based on observations made at only one point. Thus, it is important that we continue to further characterize the relation between reduction in segmental lean body mass and low back pain through longitudinal follow-up.

Accepted for publication April 28, 2000.

Reprints: Yoshitaka Toda, MD, Toda Orthopedic Rheumatology Clinic, 14-1 Toyotsu-cho, Suita, Osaka 564-0051, Japan.

Roubenoff  RRall  LC Humoral mediation of changing body composition during aging and chronic inflammation. Nutr Rev. 1993;511- 11
Link to Article
Levine  DBLeipzig  JM The Painful back. McCarty  DJKoopman  WJArthritis and Allied Conditions. 12th ed. Philadelphia, Pa. Lea & Febiger1993;1583- 1600
Andersson  GBJ Epidemiological features of chronic low-back pain. Lancet. 1999;354581- 585
Link to Article
Aro  SLeino  P Overweight and musculoskeletal morbidity: a ten-year follow-up. Int J Obes. 1985;9267- 275
Deyo  RBass  JE Lifestyle and low back pain: the influence of smoking and obesity. Spine. 1989;14501- 506
Link to Article
McGoey  BVDeitel  MSaplys  RKilman  M Effect of weight loss on musculoskeletal pain in the morbidly obese. J Bone Joint Surg Br. 1990;72322- 323
Pope  MHBevins  TWilder  DGFrymoyer  JW The relationship between anthropometric, postural, muscular, and mobility characteristics of males 18-55. Spine. 1985;10644- 647
Link to Article
Han  TSSchouten  JSLean  MESeidell  JC The prevalence of low back pain and associations with body fatness, fat distribution and height. Int J Obes Relat Metab Disord. 1997;21600- 607
Link to Article
Lee  JHOoi  YNakamura  K Measurement of muscle strength of the trunk and the lower extremities in subjects with history of low back pain. Spine. 1995;201994- 1996
Link to Article
Garzillo  MJDGarzillo  TAF Does obesity cause low back pain? J Manipulative Physiol Ther. 1994;17601- 604
Cha  KChertow  GMGonzales  JLazarus  MWilmore  DW Multifrequency bioelectrical impedance estimates the distribution of body water. J Appl Physiol. 1995;791316- 1319
Lukaski  H Methods for the assessment of human body composition: traditional and new. Am J Clin Nutr. 1987;46537- 556
Harrison  DDCailliet  RJanik  TJTroyanovich  SJHarrison  DEHolland  B Elliptical modeling of the sagittal lumbar lordosis and segmental rotation angles as a method to discriminate between normal and low back pain subjects. J Spinal Disord. 1998;11430- 439
Link to Article
Cha  KShin  SShon  CChoi  SWilmore  DW Evaluation of segmental bioelectrical impedance analysis (SBIA) for measuring muscle distribution. J Int Counc Health Phys Educ Recreation Sports Dance ASIA. Spring1997;11- 14
Perry  ACMiller  PCAllison  MDJackson  MLApplegate  EB Clinical predictability of the waist-to-hip ratio in assessment of cardiovascular disease risk factor in overweight, premenopausal women. Am J Clin Nutr. 1998;681022- 1027
Harts  AJRupley  DCRimm  AA The association of girth measurement with disease in 32,856 women. Am J Epidemiol. 1984;11971- 80
Kalkhoff  RKHartz  AHRupley  DKissebah  AHKelber  S Carbohydrate tolerance, and plasma lipids in healthy obese women. J Lab Clin Med. 1983;54254- 260
Lean  MEJHan  TSSeidell  JC Impairment of health and quality of life in people with large waist circumference. Lancet. 1998;351853- 856
Link to Article
Leboeuf-Yde  CKyvik  KOBruun  NH Low back pain and lifestyle, part II: obesity. Spine. 1999;24779- 784
Link to Article
Moffett  JKTorgerson  DBell-Syer  S  et al.  Randomised controlled trial of exercise for low back pain: clinical outcomes, cost, and preferences. BMJ. 1999;319279- 283
Link to Article
Matsui  HMaeda  ATsuji  HNaruse  Y Risk indicators of low back pain among workers in Japan: association of familial and physical factors with low back pain. Spine. 1997;221242- 1248
Link to Article

Figures

Place holder to copy figure label and caption

Body composition measurements. RRU indicates resistance of the right upper extremity segment; RLU, resistance of the left upper extremity segment; RT, resistance of the trunk segment; A, circumference of waist; B, circumference of hip; RRL, resistance of the right lower extremity segment; RLL, resistance of the left lower extremity segment; E1, right palm electrode; E2, right thumb electrode; E3, left palm electrode; E4, left thumb electrode; E5, right ball of the foot electrode; E6, right heel of the foot electrode; E7, left ball of the foot electrode; E8, left heel of the foot electrode; R1, thumb; R2, palm; R3, heel; and R4, front foot.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Characteristics of the Chronic Low Back Pain and Control Groups*
Table Graphic Jump LocationTable 2. Anthropometric Data of the Male Groups*
Table Graphic Jump LocationTable 3. Anthropometric Data of the Female Groups*

References

Roubenoff  RRall  LC Humoral mediation of changing body composition during aging and chronic inflammation. Nutr Rev. 1993;511- 11
Link to Article
Levine  DBLeipzig  JM The Painful back. McCarty  DJKoopman  WJArthritis and Allied Conditions. 12th ed. Philadelphia, Pa. Lea & Febiger1993;1583- 1600
Andersson  GBJ Epidemiological features of chronic low-back pain. Lancet. 1999;354581- 585
Link to Article
Aro  SLeino  P Overweight and musculoskeletal morbidity: a ten-year follow-up. Int J Obes. 1985;9267- 275
Deyo  RBass  JE Lifestyle and low back pain: the influence of smoking and obesity. Spine. 1989;14501- 506
Link to Article
McGoey  BVDeitel  MSaplys  RKilman  M Effect of weight loss on musculoskeletal pain in the morbidly obese. J Bone Joint Surg Br. 1990;72322- 323
Pope  MHBevins  TWilder  DGFrymoyer  JW The relationship between anthropometric, postural, muscular, and mobility characteristics of males 18-55. Spine. 1985;10644- 647
Link to Article
Han  TSSchouten  JSLean  MESeidell  JC The prevalence of low back pain and associations with body fatness, fat distribution and height. Int J Obes Relat Metab Disord. 1997;21600- 607
Link to Article
Lee  JHOoi  YNakamura  K Measurement of muscle strength of the trunk and the lower extremities in subjects with history of low back pain. Spine. 1995;201994- 1996
Link to Article
Garzillo  MJDGarzillo  TAF Does obesity cause low back pain? J Manipulative Physiol Ther. 1994;17601- 604
Cha  KChertow  GMGonzales  JLazarus  MWilmore  DW Multifrequency bioelectrical impedance estimates the distribution of body water. J Appl Physiol. 1995;791316- 1319
Lukaski  H Methods for the assessment of human body composition: traditional and new. Am J Clin Nutr. 1987;46537- 556
Harrison  DDCailliet  RJanik  TJTroyanovich  SJHarrison  DEHolland  B Elliptical modeling of the sagittal lumbar lordosis and segmental rotation angles as a method to discriminate between normal and low back pain subjects. J Spinal Disord. 1998;11430- 439
Link to Article
Cha  KShin  SShon  CChoi  SWilmore  DW Evaluation of segmental bioelectrical impedance analysis (SBIA) for measuring muscle distribution. J Int Counc Health Phys Educ Recreation Sports Dance ASIA. Spring1997;11- 14
Perry  ACMiller  PCAllison  MDJackson  MLApplegate  EB Clinical predictability of the waist-to-hip ratio in assessment of cardiovascular disease risk factor in overweight, premenopausal women. Am J Clin Nutr. 1998;681022- 1027
Harts  AJRupley  DCRimm  AA The association of girth measurement with disease in 32,856 women. Am J Epidemiol. 1984;11971- 80
Kalkhoff  RKHartz  AHRupley  DKissebah  AHKelber  S Carbohydrate tolerance, and plasma lipids in healthy obese women. J Lab Clin Med. 1983;54254- 260
Lean  MEJHan  TSSeidell  JC Impairment of health and quality of life in people with large waist circumference. Lancet. 1998;351853- 856
Link to Article
Leboeuf-Yde  CKyvik  KOBruun  NH Low back pain and lifestyle, part II: obesity. Spine. 1999;24779- 784
Link to Article
Moffett  JKTorgerson  DBell-Syer  S  et al.  Randomised controlled trial of exercise for low back pain: clinical outcomes, cost, and preferences. BMJ. 1999;319279- 283
Link to Article
Matsui  HMaeda  ATsuji  HNaruse  Y Risk indicators of low back pain among workers in Japan: association of familial and physical factors with low back pain. Spine. 1997;221242- 1248
Link to Article

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