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research report

Anne J. Smith, PhD1 Peter B. OSullivan, PhD2 amity C. CamPBell, PhD3 leOn m. Straker, PhD4

The Relationship Between Back Muscle Endurance and Physical, Lifestyle, and Psychological Factors in Adolescents
mproving the endurance of the back muscles to optimize performance is a common focus in specific sporting groups and manual work populations.27 Assessment and training of back muscle endurance (BME) is also a common focus of clinical strategies for both the prevention and management of low back pain (LBP) in adult32 and adolescent populations.28 Impairments in
BME have been reported in both general and sporting populations in adults and adolescents with reported associations with LBP.5,28 Impairment of BME
t StuDy DeSiGn: Cross-sectional investigation.

is also predictive of new episodes of LBP in some populations.8 There is some evidence that interventions directed to improving BME are effective in reducing
Backwards stepwise multivariate linear regression was used to determine statistically significant independent correlates of BME. plained 15.3% of the variance in BME and included at least 1 variable from the physical, lifestyle, and psychological domains. Adolescents who exercised less, watched more television, had a higher body mass index, sat in a more flexed trunk posture (more slumped), and had lower self-efficacy had lower BME.

t OBJeCtive: To identify the relationship between physical, lifestyle, and psychological variables and BME in a large adolescent population, while controlling for back pain and gender.

t BaCkGrOunD: There is some evidence that interventions directed to improving back muscle endurance (BME) in adolescents are effective in reducing low back pain, with anecdotal evidence of improved performance. However, the mechanisms responsible for this improvement remain unclear.

t reSultS: The final multivariate model ex-

t metHODS: One thousand four-hundred thirtyfive adolescents (702 females, 733 males; mean SD age, 14.0 0.2 years) completed a range of physical, lifestyle, and psychological assessments. The group mean SD height and body mass were 164 8 cm and 57.1 12.6 kg, respectively. Linear regression was used to investigate the univariate association between each of the physical, lifestyle, and psychological variables and BME.

t COnCluSiOnS: All the physical and lifestyle variables linked with poorer BME performance in this investigation are indicative of reduced back muscle activation and/or deconditioning. Psychological predictors may have direct and/or indirect links with BME. J Orthop Sports Phys Ther 2010;40(8):517-523. doi:10.2519/jospt.2010.3369
ance, exercise, performance, Raine study

t key WOrDS: adolescents, back muscle endur-

LBP in both sporting and nonsporting populations,28,32 with anecdotal evidence of improved performance. However, the mechanisms responsible for this improvement remain unclear.21 The Biering-Sorenson test of BME8 has demonstrated moderate to high reliability correlation coefficients (0.66, 0.98) in both patients with LBP and the general population.18,24 The test appears to offer moderate construct validity, with fatigue the most common reason reported for test termination (62.5%).30 Despite potential confounding factors to test performance, electromyography and near infrared spectroscopy have confirmed fatigue at the muscular level of the erector spinae during the test, and, therefore, the Biering-Sorenson test remains the most widely used and accepted clinical BME assessment tool.23 Few investigations have attempted to identify factors associated with BME. Differences between genders in BME performance have consistently been demonstrated, with females having greater BME than males despite the greater strength of males.17,21 The reason for this is not entirely clear, although it has been reported that females have a greater proportion of fatigue-resistant type 1 muscle fibers in their back extensors than males.20 Gib-

Postdoctoral Research Fellow, School of Physiotherapy, Curtin University of Technology, Perth, Australia; Doctor, Telethon Institute for Child Health Research, Perth, Australia. Professor, School of Physiotherapy, Curtin University of Technology, Perth, Australia; Associate Professor, Telethon Institute for Child Health Research, Perth, Australia. 3 Research Fellow, School of Physiotherapy, Curtin University of Technology, Perth, Australia. 4 Senior Research Fellow and Director of Research, School of Physiotherapy, Curtin University of Technology, Perth, Australia; Professor, Telethon Institute for Child Health Research, Perth, Australia. This study was approved by The Curtin University of Technology Human Research Ethics Institutional Review Committee. Address correspondence to Dr Anne Smith, School of Physiotherapy, Curtin University of Technology, Perth WA 6845, Australia. E-mail: A.Smith@curtin.edu.au
1 2

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bons et al11 reported that familial aggregation (the combined effects of genetics and childhood environment) explained the greatest proportion of group variance in BME time (15%). However, further clarification of the independent effect of genetics and shared early environment in an investigation that included both dizygotic and monozygotic twins indicated that genetics alone contributed only 5% of the variance in BME.31 Potential modifiable correlates of BME fall into 3 categories: physical, lifestyle, and psychological. A lower percentage of body fat has been found to be significantly associated with greater BME.11,22 However, this has not been investigated in an adolescent population. Similarly, the relationship between posture and BME has not been comprehensively examined in a large population. Nonneutral lumbar postures may be linked with poor BME. For instance, adopting slump-sitting postures has been found to result in reduced back muscle (superficial lumbar multifidus and thoracic erector spinae) activity.26 Furthermore, slump-sitting postures and greater time sitting were associated with poorer BME in a small group of male industrial workers.27 It is proposed that prolonged slump-sitting postures that reduce back muscle activity may result in deconditioning of the back musculature. Potential lifestyle correlates include levels of physical and sedentary activity. Physical activity leads to general muscle conditioning. Greater frequency and intensity of exercise were previously found to significantly predict greater BME,11 with time spent performing sedentary behaviors reported to be associated with lower levels of BME.27 The relationship between BME and psychological factors has not been explored to date, despite inferences that cognitive processes, such as motivation, might influence performance.17 Psychological factors may both mediate test performance and have indirect relationships with BME through pathways involving other physical variables (eg, posture,

research report
body mass index [BMI]) and lifestyle variables (eg, sedentary activity patterns). The presence of LBP may also act as a confounder for assessing BME due to factors such as pain inhibition, differences in pain tolerance, and fear-avoidance behaviors.21 Surprisingly, previous work showed no relationship between pain tolerance and fear-avoidance behavior and BME in patients with LBP.9 Exploring the relationship between a number of physical, lifestyle, and psychological variables with BME in a large adolescent population, while controlling for back pain and gender, will for the first time allow the identification of the modifiable factors from all 3 of these domains which are associated with BME performance. This will help clinicians and fitness personnel better understand the factors associated with BME and thus inform practice.

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Physical assessments
Participants underwent a number of physical assessments. Measures of height and body mass were used to calculate each participants BMI (body mass/height2). BME was measured with a modification of the Biering-Sorenson method. This required participants to lie prone, with their lower body supported on a plinth and held by 1 strap. The subjects trunk, from the level above the anterior superior iliac spines, was unsupported. The test required participants to hold their trunk level with their lower body for as long as possible. A handheld inclinometer was positioned at the thoracolumbar junction to ensure that a horizontal position was maintained. Subjects were instructed to maintain the horizontal position for as long as they could, with standard feedback being given to the subject to maintain the position. Lowering of the trunk greater than 10 resulted in test termination. Time for the test, in seconds, was monitored using a handheld stopwatch. Posture assessments were carried out with the participant in a sitting position. Retroreflective markers were fixed over the C7 and T12 spinous processes and the greater trochanter. A digital camera captured each participants habitual posture from a lateral perspective. Participants sat on a stool that was adjusted to popliteal height and were instructed to sit as they usually would with their gaze fixed straight ahead. Following the digitization of each marker point using the Peak Motus motion analysis system (Peak Performance Technologies Inc, Alpharetta, GA), the angle between 2 vectors, one connecting the C7 and T12 markers and the other the T12 and greater trochanter markers, was calculated as representative of trunk angle in accordance with previous research.29,35

metHODS
Sample
ata were collected from adolescents participating in the Raine Child Health Study (http://www. rainestudy.org.au), a longitudinal investigation on a range of health and development issues. The study started as a pregnancy cohort, in which 2900 women between 16 and 20 weeks of gestation were enrolled from the antenatal clinics at King Edward Memorial Hospital for Women in Perth, Western Australia, between 1989 and 1991. The children have been followed from birth to the ages of 1, 2, 3, 5, 8, 10, and now 14 years. One thousand four-hundred thirty-five adolescents (702 females, 733 males; mean SD age, 14.0 0.2 years) at the 14-year follow-up completed all of the, physical, lifestyle, and psychological assessments utilized in this investigation. The mean SD height and body mass for this group were 164 8 cm and 57.1 12.6 kg, respectively. The Curtin University of Technology Human Research Ethics Institutional Review Committee granted ethical approval, and each participants guardian provided informed consent.

Questionnaire assessments
The full data collection included a number of questionnaires regarding both lifestyle and psychological variables. Lifestyle factors(1) television (TV)

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usage, (2) computer usage, and (3) outof-school moderate/strenuous physical activitywere assessed using previously reported items.15 For TV use, subjects were asked, On average, how many hours a day do you usually watch TV or videos (including school days and weekends)? For computer use, subjects were asked, On average, how many hours a day do you usually play video games or computer games, use the internet, or chat online (including school days and weekends)? Both responses were categorized as none, less than 1 hour, about 1 to 2 hours, about 3 to 4 hours, or 4 hours or more a day. For the purposes of statistical analysis, the category none of TV use was merged with less than 1 hour, due to the low numbers in the none response category (taBle 1). For exercise levels, subjects were asked, Outside school hours, how many hours do you usually exercise in your free time so much that you get out of breath or sweat? Responses to this question were categorized as none, about half hour a week, about 1 hour a week, about 2 to 3 hours a week, about 4 to 6 hours a week, or 7 or more hours a week. The current investigation utilized 4 psychological indices.
Cowens Perceived Self-Efficacy Scale10 The questionnaire is comprised

taBle 1

Descriptive Statistics for Back Muscle Endurance and Physical, Lifestyle, and Psychological Factors by Gender and Overall
males (n = 733) Females (n = 702) 86.3 64.4 29% 21.4 4.0 225.9 10.6 total (n = 1435) 83.0 62.7 27% 21.1 4.0 232.3 12.7 79.8 61.0 26% 20.9 3.9 238.4 11.5

Biering-Sorenson Score (s)* Experience of back pain in the last month (%) Physical factors* Body mass index (kg/m2) Sitting trunk angle () Lifestyle factors Daily television use None 1 h 1-2 h 3-4 h 4 h Daily computer use None 1 h 1-2 h 3-4 h 4 h Weekly exercise level None 1/2 h 1h 2-3 h 4-6 h 7 h Psychological factors* Cowen's Perceived Self-Efficacy Harter's Self-Perception Profile Beck's Depression Inventory Child Behavior Checklist
* Values are presented as mean SD. Values are presented as n (%).

9 (1.2) 95 (13.0) 251 (34.2) 278 (37.9) 100 (13.7) 44 (6.0) 243 (33.1) 245 (33.4) 126 (17.2) 75 (10.2) 31 (4.2) 92 (12.6) 86 (11.7) 226 (30.8) 171 (23.4) 127 (17.3 ) 3.4 0.6 3.2 0.5 4.9 5.3 36.1 18.2

14 (2.0) 119 (16.9) 236 (33.6) 236 (33.6) 97 (13.8) 104 (14.8) 284 (40.5) 180 (25.6) 95 (13.5) 39 (5.6) 49 (7.0) 126 (17.9) 118 (16.8) 238 (33.9) 126 (18.0) 45 (6.4) 3.2 0.6 3.1 0.6 7.7 7.5 40.7 20.5

23 (1.6) 214 (14.9) 487 (33.9) 514 (35.8) 197 (13.7) 148 (10.3) 527 (36.7) 425 (29.6) 221 (15.4) 114 (7.9) 80 (5.6) 218 (15.2) 204 (14.2) 464 (32.3) 297 (20.7) 172 (12.0) 3.4 0.6 3.1 0.5 6.3 6.6 38.3 19.5

of 22 items, by which respondents rate their confidence to manage a variety of common situations on a 5-point scale ranging from 0 (not at all sure) to 4 (very sure). This questionnaire shows high internal consistency and evidence of convergent and concurrent validity. 16 Item responses are summed to provide a total score ranging from 0 to 88, with lower scores indicating less self-efficacy.
Harters Self-Perception Profile for Adolescents9 The 5-item Global Self-Worth

Becks Depression Inventory for Youth This is a 20-item scale used to

subscale was used. Items are scored from 1 (low worth) to 4 (high worth), then summed and averaged to provide a global score, with lower scores indicating less self-worth. This measure has good internal consistency.12

assess depressed mood in early adolescence. The Becks Depression Inventory for Youth has high internal consistency and excellent test-retest reliability over 7 days.7 A higher score indicates greater depressed mood.
The Youth Self-Report Version of the Child Behavior Checklist (CBCL)2 This

internal consistencies for both boys and girls.3 Raw total scores were used for analysis, as recommended by Achenbach,1 for research involving distinctions between children with mild symptoms, with a higher score indicating more negative attributes. Participants were also asked if their back had been painful in the last month.

112-item self-report questionnaire measures a range of adolescent behavioral and emotional problems, and has high

Statistics
Statistical analysis was performed using Stata/IC 10.1 for Windows (Statacorp 519

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LP, College Station, TX). Statistical significance was set at = .05. Two-sample t tests or chi-squared tests were used to evaluate gender differences in covariates. Linear regression analysis was used to examine the univariate association of each physical, lifestyle, and psychological independent variables with BME, as indicated by their Biering-Sorenson time, after confirming the assumption of linearity of relationships. Backwards stepwise multivariate linear regression, with probability of removal of = .05, was used to determine statistically significant independent correlates of BME from the range of multidimensional variables considered, with forward stepwise method confirming results. All models were adjusted for the potential confounding effects of gender and LBP. Clinically meaningful interactions were considered and tested but none detected (eg, modifying effect of gender on other covariate relationships with BME).

research report

taBle 2

Univariate Analyses of Physical, Lifestyle, and Psychological Factors Associated With Back Muscle Endurance, Adjusted for Gender and Experience of Back Pain in the Last Month (n = 1435)
Coefficient* 95% Ci 0.07, 13.16 12.28, 2.29 5.38, 3.82 1.52, 0.95 12.04, 5.07 5.91, 0.14 5.24, 9.95 11.89, 20.91 9.65, 19.52 7.25, 0.94 13.38, 4.50 P value .048 .179 .001 .001 .001 .062 .001 .001 .001 .131 .001 6.57 4.99 4.60 1.24 8.56 2.88 7.60 16.40 14.59 3.16 8.94

Female gender Experience of back pain in the last month Physical factors Body mass index (kg/m2) Sitting trunk angle () Lifestyle factors Daily television use (4 categories) Daily computer use (5 categories) Weekly exercise level (6 categories) Psychological Factors Cowen's Perceived Self-Efficacy Harter's Self-Perception Profile Beck's Depression Inventory Child Behavior Checklist

reSultS
Descriptive results
provides descriptive data for all variables utilized in this investigation. The mean SD BME for females (86.3 64.6 seconds) was greater than that for males (79.8 61.0; P = .048). Although more females reported back pain in the last month (205/702 [29%]) than males (188/733 [26%]), this difference was not statistically significant (P = .131). The BMI for the group indicates that most of the adolescents were within a healthy body mass range. The mean SD sitting trunk angle was 232.3 12.7, with males in a more flexed or slumped position than females (difference, 12.5; 95% CI: 11.4, 13.7; P.001). Most adolescents reported either 1 to 2 or 3 to 4 hours a day watching TV, with males reporting higher levels of use (P = .070). (As previously stated, the TV use categories none and less than 1 hour a day were merged for further analysis, due to the very low frequency in the lowest
aBle 1

Abbreviation: CI, confidence interval. * coefficient represents the estimated change in seconds in Biering-Sorenson test time for 1 unit change in independent variable. coefficient represents the estimated change in seconds in Biering-Sorenson test time for individuals at 25th versus 75th percentiles.

category.) Most adolescents reported using computers less than 2 hours a day, with males reporting higher levels of use (P.001). Most adolescents reported doing 2 to 3 hours of weekly exercise (32%), with males reporting higher duration of exercise (P.001). Females demonstrated significantly lower selfefficacy (Cowens), self-perception (Harters), mood (Becks), and higher levels of behavioral problems (CBCL) than the males (P.001 for all contrasts).

between duration of daily TV use and BME, but no significant relationship between duration of computer use and BME. There was a strong positive relationship between duration of weekly exercise and BME. Three of the 4 psychological factors were associated with BME. Participants with higher self-efficacy and self-perception scores performed better in the BME test, whereas participants with higher CBCL scores performed poorer in the BME test.

univariate analysis of Bme Correlates

The results of the univariate linear regression analyses are presented in taBle 2. As mentioned above, females demonstrated a significantly higher mean BME than males. Experience of back pain in the last month was not significantly associated with BME. Higher BMI and trunk angle (a more slumped posture) were associated with lower BME. The analysis of the lifestyle variables revealed a strong negative relationship

multivariate model
The results of the stepwise multivariate linear regression analysis are presented in taBle 3. After accounting for back pain and gender, 5 variables remained in the final multivariate model. BMI was the most significant factor associated with BME, followed by Cowens perceived self-efficacy, sitting trunk angle, duration of weekly exercise, and duration of daily TV use.

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taBle 3

Stepwise Multivariate Regression Analysis of Physical, Lifestyle, and Psychological Factors Associated With Back Muscle Endurance, Adjusted for Gender and Pain (n = 1435)
Coefficient* 95% Ci 3.47, 10.97 8.59, 4.91 4.81, 3.26 5.75, 14.72 0.97, 0.40 2.84, 7.40 8.39, 1.81 P value .308 .593 .001 .001 .001 .001 .003 R2 0.003 0.004 0.088 0.120 0.135 0.148 0.153 0.001 0.084 0.032 0.015 0.013 0.005 R2 Change 3.75 1.84 4.04 10.24 0.68 5.12 5.10

Female gender Back pain in the last month Body mass index (kg/m2) Cowen's Perceived Self-Efficacy Sitting trunk angle () Weekly exercise level (6 categories) Daily television use (4 categories)

Abbreviation: CI, confidence interval. * coefficient represents change in seconds of Biering-Sorenson test time for 1 unit change in independent variable. coefficient represents the estimated change in seconds in Biering-Sorenson test time for individuals at 25th versus 75th percentiles of each score.

the current study is only cross-sectional, it is also possible that individuals adopted a flexed sitting posture secondary to reduced endurance of the back extensors. Greater BMI in this adolescent population was strongly linked with poorer BME, consistent with previous research on adult populations.22 BMI has been demonstrated to be a good representation of adiposity in adolescents, particularly in large cohorts.19 However, further research clarifying the ratios between adipose, skeletal, and muscle tissues and their relative distributions is required to clarify the direct mechanism linking BMI and BME performance.

lifestyle variables
Longer duration of TV use and fewer hours of exercise were related to poorer performance in BME assessment in the current study. Previous research has reported that more leisure or occupational physical activities were linked with greater BME in adults.11,27 The current findings show that this relationship is already evident in adolescents. It would therefore appear that lifestyle variables associated with sedentary behavior are linked with poorer BME. Duration of computer use had a similar negative relationship as duration of TV use to BME in this study, although the estimated effect was weaker and not statistically significant. This may be the result of the overall lower level of computer use reported by participants or the possibility that adolescents maintain more active sitting postures when using a computer versus watching TV.

DiSCuSSiOn
his investigation aimed to identify the relationship between a selection of potentially modifiable physical, lifestyle, and psychological variables and BME performance in a large adolescent sample, accounting for gender and LBP. Univariate analyses revealed independent relationships between each variable and BME test performance. Although back pain in the last month was not significantly associated with the BME score in the present results, this was also accounted for in the final model, given prior research indicating that this would be a potential confounder.32 The fact that back pain in the last month was not associated with BME is contrary to other reports from general adult and sporting populations and adolescents.27,28,32 Our ongoing investigations will examine whether subgroups exist in which BME deficits are associated with LBP, as the limitation of large epidemiological studies is the risk of a washout effect, where subgroups of LBP with high and low BME scores obscure an association. In agreement with previous research, females had significantly better BME than males on univariate analysis.17 However, this gender difference did not remain after adjusting for other covari-

ates. Detailed analysis revealed the major confounder of the gender-BME relationship was sitting posture. Males sat with greater spinal flexion, which was associated with poorer BME. Previous research has indicated differences between gender in skeletal muscle composition. Females erector spinae muscles have been shown to contain a greater proportion of slowtwitch (endurance) muscle fibers than those of males,20 which may partly explain both their propensity to maintain more upright sitting posture and their higher BME test performance.

Physical variables
Both physical measures analyzed were significantly associated with BME, independent of other factors. Sitting trunk angle was demonstrated to be linked with poorer BME. The link between posture and BME may relate to the relaxation of the back muscles during more flexed spinal sitting postures potentially leading to deconditioning if these postures are habitually sustained.25 This finding is consistent with the suggestion that postural training is important when attempting to improve BME34 and the findings of Perich et al,28 who reported that greater BME was associated with more upright sitting postures following a specific exercise intervention. However, as

Psychological variables
The current investigation demonstrated that adolescents who had lower perceived self-efficacy (as indicated by the Cowens Perceived Self-Efficacy), lower overall self-perception (as indicated by the Harters Self-Perception Profile), and more behavioral problems (as indicated by the CBCL) had poorer BME. Previous research investigating factors associated with BME has not included psychological variables. As these 3 psychological mea521

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sures were moderately correlated, only perceived self-efficacy, the variable most strongly related to BME, remained in the final model. Perceived self-efficacy indicates a persons beliefs about the capability to achieve a nominated performance level. Self-efficacy beliefs determine how people feel, think, motivate themselves, and behave. Although the link between negative psychological parameters and poorer BME performance is not clear, it could be that negative psychological factors mediate Biering-Sorensen test performance via reduced motivation.33 Alternatively, negative psychological factors have been demonstrated to be associated with lesser levels of physical activity,3 higher BMI,11 and more slumped postures.36 Although adjusting for these factors in this study resulted in a reduced effect of self-efficacy, there was still a significant independent relationship between self-efficacy and BME. The finding of an association between a range of psychological measures and BME supports future investigation of the possible mechanisms for this effect. Only 15% of the variance in BME was accounted for by factors across multiple domains. This would suggest that other important correlates of BME exist that were not considered in the present study, including genetics, muscle characteristics such as density, area, fiber composition and recruitment patterns, and possibly general health, sleep patterns, pressurepain thresholds, and stress responsiveness. In addition, inadequate capture of underlying constructs by the measured variables, such as physical activity, may also partly explain the residual variation in BME. Interestingly, the physical, lifestyle, and psychological factors accounted for a similar proportion of BME variance as the familial aggregation factors reported by Gibbons et al,11 indicating that the factors that affect BME are multidimensional.

research report
cal, lifestyle, and psychological factors. These findings may hold importance for healthcare providers and fitness personnel, where the aim is to improve BME in the prevention and management of LBP. If BME is also found to be important for sporting and occupational performance, then these findings may be valuable in guiding interventions aimed to enhance performance. A range of multidimensional factors, such as obesity, physical activity levels, sedentary activity levels, habitual sitting postures, and psychological factors, such as behaviors, mood, selfefficacy, and self-perception, may need to be considered in a rehabilitation and or training program to optimize performance. Further, it is likely that, for each individual, different clusters of factors need to be addressed to enhance BME.

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to optimize performance. CautiOn: This study was conducted on a large population of 14-year-old adolescents in Western Australia, thus may not be representative of similarly aged populations from other countries.
Acknowledgements: Funding has been re-

ceived from the Australian National Health and Medical Research Council, the Raine Medical Research Foundation at the University of Western Australia, the Arthritis Foundation of Western Australia, and the Arthritis Foundation of Australia. Data collection by Rosemary Austin, Lee Clohessy, Alex DVauz, Monique Robinson, Nick Sloan, and Diane Wood. Data processing by Jemma Coleman and Clare Haselgrove. We thank the study participants and their families.

COnCluSiOn
The final multivariate model explained 15% of the variance in BME and included at least 1 variable from each of the 3 domains investigated (physical, lifestyle, and psychological). Adolescents who had a higher BMI, sat in a more flexed trunk posture (more slumped), exercised less, watched more TV, and had lower self-efficacy had lower BME. All the physical and lifestyle variables linked in this investigation with poorer BME performance are indicative of reduced muscle activation and/or deconditioning. Psychological correlates may have direct and/or indirect links with BME. t

reFerenCeS
1. Achenbach TM. Integrative Guide for the 1991 CBCL 4-18, YSR, and TRF Profiles. Burlington, VT: University of Vermont; 1991. 2. Achenbach TM. Manual for Child Behavior Checklist 4-18, 1991 Profile. Burlington, VT: University of Vermont; 1991. 3. Achenbach TM. Manual for the Youth Self-Report and 1991 Profile. Burlington, VT: University of Vermont; 1991. 4. Andersen RE, Crespo CJ, Bartlett SJ, Cheskin LJ, Pratt M. Relationship of physical activity and television watching with body weight and level of fatness among children: results from the Third National Health and Nutrition Examination Survey. JAMA. 1998;279:938-942. 5. Astflack R, OSullivan P, Straker L, Smith A. Characteristics of non-specific chronic low back pain in an adolescent population. Musculoskeletal Physiotherapy Australia 15th Biennial Conference, 2007, Cairns, Queensland, Australia. 6. Beck AT, Beamesderfer A. Assessment of depression: the depression inventory. Mod Probl Pharmacopsychiatry. 1974;7:151-169. 7. Beck JS, Beck AT, Jolly J. Beck Youth Inventories of Emotional and Social Impairment. San Antonio, TX: The Psychological Corporation; 2001. 8. Biering-Sorensen F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine (Phila Pa 1976). 1984;9:106-119. 9. Chan HL, Chiu TTW. The correlations among pain, disability, lumbar muscle endurance and fear-avoidance behaviour in patients with chronic low back pain. J Back Musculoskeletal Rehabi. 2008;21:35-42. 10. Cowen EL, Work WC, Hightower AD, Wyman

key POintS
FinDinGS: The final multivariate model

Clinical implications
The findings of this study support an association between BME and physi-

explained 15% of the variance in BME, indicating that adolescents who had a higher BMI, sat in a more flexed trunk posture (more slumped), exercised less, watched more TV, and had lower selfefficacy had lower BME. imPliCatiOn: Given that physical, lifestyle, and psychological factors are associated with BME, a range of multidimensional factors may need to be considered in a rehabilitation and/or training program

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11.

12.

13.

14.

15.

16.

17.

18.

19.

PA, Parker GR, Lotyczewski BS. Toward the development of a measure of perceived selfefficacy in children. J Clin Child Psychology. 1991;20:169-178. Gibbons LE, Videman T, Battie MC. Determinants of isokinetic and psychophysical lifting strength and static back muscle endurance: a study of male monozygotic twins. Spine (Phila Pa 1976). 1997;22:2983-2990. Guite JW, Logan DE, Sherry DD, Rose JB. Adolescent self-perception: associations with chronic musculoskeletal pain and functional disability. J Pain. 2007;8:379-386. http://dx.doi. org/10.1016/j.jpain.2006.10.006 Hakala PT, Rimpela AH, Saarni LA, Salminen JJ. Frequent computer-related activities increase the risk of neck-shoulder and low back pain in adolescents. Eur J Public Health. 2006;16:536541. http://dx.doi.org/10.1093/eurpub/ckl025 Harter S. Manual for the self-perception profile for adolescents. Denver, CO: University of Denver; 1988. Harter S. Manual for the Self-Perception Profile for Children: Revision of the Perceived Competence Scale for Children. Denver, CO: University of Denver; 1985. Hoeltje CO, Silbum SR, Garton AF, Zubrick SR. Generalized self-efficacy: family and adjustment correlates. J Clin Child Psychology. 1996;25:446-453. Kankaanpaa M, Laaksonen D, Taimela S, Kokko SM, Airaksinen O, Hanninen O. Age, sex, and body mass index as determinants of back and hip extensor fatigue in the isometric Sorensen back endurance test. Arch Phys Med Rehabil. 1998;79:1069-1075. Latikka P, Battie MC, Videman T, Gibbons LE. Correlations of isokinetic and psychophysical back lift and static back extensor endurance tests in men. Clin Biomech (Bristol, Avon). 1995;10:325-330. Lazarus R, Baur L, Webb K, Blyth F. Body mass index in screening for adiposity in children and adolescents: systematic evaluation using re-

20.

21.

22.

23.

24.

25.

26.

27.

28.

ceiver operating characteristic curves. Am J Clin Nutr. 1996;63:500-506. Mannion AF, Dumas GA, Cooper RG, Espinosa FJ, Faris MW, Stevenson JM. Muscle fibre size and type distribution in thoracic and lumbar regions of erector spinae in healthy subjects without low back pain: normal values and sex differences. J Anat. 1997;190 ( Pt 4):505-513. Mannion AF, Muntener M, Taimela S, Dvorak J. A randomized clinical trial of three active therapies for chronic low back pain. Spine (Phila Pa 1976). 1999;24:2435-2448. Mbada C, Ayanniyi O, Adedoyin R. Influence of relative adiposity on static back extensor muscle endurance in apparently healthy adults. Hong Kong Physiother J. 2008;26:2-8. http:// dx.doi.org/10.1016/S1013-7025(09)70002-8 Moreau CE, Green BN, Johnson CD, Moreau SR. Isometric back extension endurance tests: a review of the literature. J Manipulative Physiol Ther. 2001;24:110-122. http://dx.doi. org/10.1067/mmt.2001.112563 Moreland J, Finch E, Stratford P, Balsor B, Gill C. Interrater reliability of six tests of trunk muscle function and endurance. J Orthop Sports Phys Ther. 1997;26:200-208. OSullivan P, Dankaerts W, Burnett A, et al. Lumbopelvic kinematics and trunk muscle activity during sitting on stable and unstable surfaces. J Orthop Sports Phys Ther. 2006;36:19-25. http:// dx.doi.org/10.2519/jospt.2006.2094 OSullivan PB, Grahamslaw KM, Kendell M, Lapenskie SC, Moller NE, Richards KV. The effect of different standing and sitting postures on trunk muscle activity in a pain-free population. Spine (Phila Pa 1976). 2002;27:1238-1244. OSullivan PB, Mitchell T, Bulich P, Waller R, Holte J. The relationship beween posture and back muscle endurance in industrial workers with flexionrelated low back pain. Man Ther. 2006;11:264-271. http://dx.doi.org/10.1016/j.math.2005.04.004 Perich D, Burnett A, OSullivan P, Perkin C. Low back pain in adolescent female rowers: a multi-disciplinary intervention study. Knee Surg

Sports Traumatol Arthrosc. 2010;In Press. 29. Perry M, Smith A, Straker L, Coleman J, OSullivan P. Reliability of sagittal photographic spinal posture assessment in adolescents. Adv Physiother. 2008;10:66-75. http://dx.doi. org/10.1080/14038190701728251 30. Ropponen A, Gibbons LE, Videman T, Battie MC. Isometric back extension endurance testing: reasons for test termination. J Orthop Sports Phys Ther. 2005;35:437-442. http://dx.doi. org/10.2519/jospt.2005.2007 31. Ropponen A, Levalahti E, Videman T, Kaprio J, Battie MC. The role of genetics and environment in lifting force and isometric trunk extensor endurance. Phys Ther. 2004;84:608-621. 32. Roy SH, De Luca CJ, Casavant DA. Lumbar muscle fatigue and chronic lower back pain. Spine (Phila Pa 1976). 1989;14:992-1001. 33. Scully D, Kremer J, Meade MM, Graham R, Dudgeon K. Physical exercise and psychological well being: a critical review. Br J Sports Med. 1998;32:111-120. 34. Smeets RJ, Wade D, Hidding A, Van Leeuwen PJ, Vlaeyen JW, Knottnerus JA. The association of physical deconditioning and chronic low back pain: a hypothesis-oriented systematic review. Disabil Rehabil. 2006;28:673-693. http://dx.doi. org/10.1080/09638280500264782 35. Smith A, OSullivan P, Straker L. Classification of sagittal thoraco-lumbo-pelvic alignment of the adolescent spine in standing and its relationship to low back pain. Spine (Phila Pa 1976). 2008;33:2101-2107. http://dx.doi.org/10.1097/ BRS.0b013e31817ec3b0 36. Wilson VE, Peper E. The effects of upright and slumped postures on the recall of positive and negative thoughts. Appl Psychophysiol Biofeedback. 2004;29:189-195. http://dx.doi. org/10.1023/B:APBI.0000039057.32963.34

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