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Long-Term Effects of Specific Stabilizing Exercises for First-Episode Low Back Pain
- Denis Bates
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1 Long-Term Effects of Specific Stabilizing Exercises for First-Episode Low Back Pain SPINE Volume 26, Number 11, pp E243 E , Lippincott Williams & Wilkins, Inc. Julie A. Hides, PhD, MPhtySt, BPhty,* Gwendolen A. Jull, MPhty, FACP* and Carolyn A. Richardson, PhD, BPhty(Hons)* Study Design. A randomized clinical trial with 1-year and 3-year telephone questionnaire follow-ups. Objective. To report a specific exercise intervention s long-term effects on recurrence rates in acute, first-episode low back pain patients. Summary of Background Data. The pain and disability associated with an initial episode of acute low back pain (LBP) is known to resolve spontaneously in the short-term in the majority of cases. However, the recurrence rate is high, and recurrent disabling episodes remain one of the most costly problems in LBP. A deficit in the multifidus muscle has been identified in acute LBP patients, and does not resolve spontaneously on resolution of painful symptoms and resumption of normal activity. Any relation between this deficit and recurrence rate was investigated in the long-term. Methods. Thirty-nine patients with acute, first-episode LBP were medically managed and randomly allocated to either a control group or specific exercise group. Medical management included advice and use of medications. Intervention consisted of exercises aimed at rehabilitating the multifidus in cocontraction with the transversus abdominis muscle. One year and three years after treatment, telephone questionnaires were conducted with patients. Results. Questionnaire results revealed that patients from the specific exercise group experienced fewer recurrences of LBP than patients from the control group. One year after treatment, specific exercise group recurrence was 30%, and control group recurrence was 84% (P 0.001). Two to three years after treatment, specific exercise group recurrence was 35%, and control group recurrence was 75% (P 0.01). Conclusion. Long-term results suggest that specific exercise therapy in addition to medical management and resumption of normal activity may be more effective in reducing low back pain recurrences than medical management and normal activity alone. [Key Words: multifidus, low back pain, rehabilitation] Spine 2001;26:E243 E248 The major costs of low back pain (LBP) have been identified with two groups: those who develop chronic LBP and those who have recurrent disabling episodes of LBP. 12 These two groups incur 85% of the total costs. 13,23,33 Efforts have been made to identify the 2 3% of patients who go on to develop chronic symptoms, 22 but little is known about the factors that lead to recurrence. From the *Department of Physiotherapy, The University of Queensland, Brisbane, Australia, and the Department of Physiotherapy, Mater Misericordiae Public Hospitals, South Brisbane, Queensland, Australia Acknowledgment date: October 27, Acceptance date: February 13, Device status category: 1. Conflict of interest category: 12. It is documented and generally accepted that a single episode of acute LBP has a favorable natural history with respect to symptom reduction and restoration of function and work capacity in the short term. 1 In the majority of cases, the pain associated with an initial acute episode resolves within 2 4 weeks. 5,7 11,21 It is estimated that 2 3% of patients go on to develop disabling chronic LBP after an acute episode. 5,18,22 However, the course of LBP for most primary care patients is recurrent rather than acute or chronic in the usual sense of these terms. 39 When the frequency of low back pain recurrences following an acute episode is examined, the recurrence rate is found to be staggeringly high. Recurrence rates range from 60% to 86% for patients suffering recurrences, particularly in the first year after the acute episode. 3,35 37 Bergquist-Ullman and Larsson 3 conducted a detailed study of 217 workers in an industrial setting in Sweden. The median duration of pain for the initial episode was 35 days and short-term resolution of painful symptoms occurred in the majority of cases (70% within 2 months, 86% within 3 months). However, during the 1-year follow-up, 62% of the patients experienced at least one recurrence of LBP and a further 36% experienced two or more recurrences. The median time from resolution of the initial episode to the first recurrence of LBP was only 2 months. These high figures would suggest that it is important to identify the factors that may relate to this vulnerability to recurrence. Although several processes are likely to be involved, the model provided by Panjabi 26,27 could provide an explanation for recurrences after painful symptoms have subsided. This model of spinal stability encompasses the passive, active, and neural control subsystems. It has been proposed that instability at the spinal segmental level is a loss of control or excessive motion in the spinal segment s neutral zone, which is associated with injury, degenerative disc disease, and muscle weakness. 26,27 It has been shown in in vitro biomechanical studies that muscles can provide segmental stabilization by controlling motion in the neutral zone, and the neutral zone can be returned to within physiologic limits by effective muscle control. 14,28,41 While various muscles may be able to control and protect the spinal segments, one muscle that has been investigated in relation to this role is the lumbar multifidus. The multifidus provides segmental stiffness and controls motion in the neutral zone. 14,28,34,41 Further evidence of this stabilizing role has been provided by in vivo animal research. 20 Investigations have also demonstrated a relation between multifidus muscle dysfunc- E243
2 E244 Spine Volume 26 Number tion and poor functional outcome and recurrence of LBP following disc surgery. 29,32 Optimal functioning of the muscle system is desirable to control and protect the spinal segments following injury. Despite initial resolution of painful symptoms, failure to protect spinal segments could increase the likelihood of a recurrence of symptoms. Specific exercises targeting the multifidus and transversus abdominis muscles have been shown to decrease pain and disability in chronic low back pain patients. 25 Our research has shown the occurrence of localized segmental dysfunction of the multifidus muscle after an initial episode of acute unilateral LBP. 15,16 To establish the low back pain recurrence rates in the two groups, the present study presents the follow-ups of the patients from the study at 1 year and 3 years after treatment. Methods During a 6-month period, patients were recruited from a hospital accident and emergency department. 16 Men and women were eligible for the initial study if they were aged 18 to 45 years, were experiencing their first episode of unilateral mechanical LBP for less than 3 weeks, and presented to the accident and emergency department because of this condition. Inclusion and exclusion criteria are provided in detail elsewhere. 16 Thirty-nine patients were accepted into the study. All patients gave their consent and the Medical Ethical Review Committees of the University of Queensland and the Mater Adult Hospital, Brisbane, Australia approved the study. Assessment Procedures. Assessments for the short-term phase of the trial were performed by two independent examiners, who were blinded to group allocation and patient presentation. The following assessments were conducted to establish baseline levels and to monitor improvement over time: pain (McGill Pain Questionnaire and Visual Analogue Scales), disability (Roland Morris Disability Index), range of motion (using inclinometers), habitual activity levels, 2 and muscle crosssectional area (using ultrasound imaging). 16 The aim of the long-term follow-ups was to determine the incidence of recurrence of LBP. To meet this aim, a telephone questionnaire was selected as the most appropriate assessment tool. Methodologic research has indicated that well-designed telephone interviews provide results comparable to face-to-face interviews 6 and investigations of pain data obtained in this way also support the validity of telephone interviews. 38,39 The questionnaires were administered by a research assistant who was not involved in the first stage of the study and who was blind to group allocation. The questionnaires used to determine the recurrence rate of LBP episodes during the 1-year and 3-year year follow-up periods were devised especially for the patients in this study, as the information sought was specific to the design and methods implemented. The questionnaire consisted of three groups of questions, and took approximately 5 minutes to complete. Questions related to episodes of LBP experienced in the year after the study (1-year follow-up) and then in years two to three (3-year follow-up). A general opening question was used to determine whether patients had experienced any episodes of LBP in the time period in question. Subsequent questions determined the number of episodes experienced in that time frame, their length, severity, precipitating factors, and treatment sought. Ideally, it would have been useful to reimage the patients multifidus muscles. This was not possible because many of the patients had relocated interstate or overseas. Intervention and Patient Management. Patients in Group 1 (control group) received medical management, including advice on bedrest, absence from work, prescription of medication, and advice to resume normal activity as tolerated, whereas those in Group 2 (specific exercise group) additionally performed specific localized exercises aimed at restoring the stabilizing protective function of the multifidus. The exercises were designed specifically to activate and train the isometric holding function of the multifidus muscle at the affected vertebral segment (in cocontraction with the transversus abdominis muscle). Contraction of the multifidus was confirmed by realtime ultrasound imaging. This rehabilitation approach is described in detail elsewhere. 17,19,30,31 The intervention period was 4 weeks, and patients from the specific exercise group were seen twice per week in this period. Statistical Analysis. Data analysis was performed using the SPSS statistics program. Comparability of baseline measurements between the two groups was assessed using a one-way analysis of variance (ANOVA) to examine differences in all baseline measurements. ANOVA also was used to examine differences between groups over time for all outcome measures used. For ultrasound imaging data, the percentage difference between the painful and nonpainful side was calculated for each vertebral level measured. Analysis of muscle recovery was conducted using the data from the most affected vertebral level (i.e., the vertebral level with the largest percentage difference between sides). For the 1-year and 2 3-year follow-up analysis, the data were expressed as the likelihood of recurring LBP in the control group relative to that in the intervention group. A relative risk ratio of 1.00 indicates that patients in both groups were equally likely to report recurring LBP. A large risk ratio indicates that the treatment was effective, while a ratio less than one would indicate that the treatment increased the likelihood of recurrence. The significance of the treatment was determined with a 2 test. Because the three patients who were lost for 2 3-year follow-up were all from the control group, the analysis was repeated using the best case analysis, assuming that the three patients had all completely recovered, and did not suffer recurrences in this period. Results Study Sample Patients were randomly allocated to Group 1 (control, n 19) or Group 2 (specific exercise, n 20). The demographics for the groups are shown in Table 1. Baseline Characteristics Comparability between groups was found to be satisfactory at baseline for age, height, weight, duration of symptoms, premorbid activity, and outcome measures used. 16 Primary Outcomes for Weeks 1 4 Results of the short-term study have been presented in detail in an earlier report, 16 but in summary, ultrasound imaging revealed that asymmetry of the multifidus muscle was present with diminished muscle size evident on
3 Stabilizing Exercises for Low Back Pain Hides et al E245 Table 1. Demographic Data for Groups 1 (Control) and 2 (Specific Exercise) Group 1 (Control) n 19 Group 2 (Specific Exercise) n 20 Mean SD Range Mean SD Range Age (years) Gender 9 male, 10 female 7 male, 13 female Height (cm) Weight (kg) Duration of Symptoms (Days) Smokers 7 4 Worker s Compensation 5 8 Pre-morbid Activity Levels Work Sport Leisure the patient s nominated painful side in all cases. The difference between the sides at the most affected vertebral level was expressed as a percentage of the CSA for the unaffected side at that level. The mean of these percentages was 22% 8.7% for the control group and 26% 8.7% for the specific exercise group (range, 12 46%). Results at follow-up immediately after the intervention period and at a 10-week follow-up examination revealed that multifidus muscle recovery was not spontaneous on remission of painful symptoms in control group patients. In the control group, multifidus CSA at the most affected vertebral level remained 16.8% 9.3% less at 4 weeks and 14% 6.3% less at ten weeks. Muscle recovery was more rapid and more complete in patients in Group 2 who received specific and localized exercises (P ). Multifidus CSA at the most affected vertebral level was only 0.7% 2.5% less at 4 weeks and 0.2% 3.3% less at ten weeks. The other outcome measurements of disability and physical function were similar for the two groups at the 4-week examination (pain and disability had completely resolved in 90% of the patients). Although they resumed normal levels of activity, patients in Group 1 still exhibited significantly decreased multifidus muscle size at the 10-week follow-up examination, and the difference between groups was still significant (P ). Long-Term Follow-Up Study Sample The response rate to the questionnaire at 1 year was 100%, with all 39 patients interviewed. Three patients could not be contacted for the 3-year interview, despite records of work, residence, mobile phone, and stable relative contact. All three were from the control group. For the 3-year follow-up interview, questions related to recurrence of symptoms in the previous 2 years. Overall Recurrence Rate and Risk of Recurrences Results of the contingency 2 analysis revealed that, in the year after the initial episode, patients in the control group were 12.4 times more likely to experience recurrences of LBP than patients in the specific exercise group (x 2 (1) 12.41, P 0.001). Additionally, these patients were 9 times more likely to experience LBP recurrences in years 2 3 (x 2 (1) 9.31, P 0.01). The risk of pain for each group is presented in Table 2, along with confidence intervals. In year 1, approximately 1 patient in the specific exercise group reported pain for every 3 patients who did not, whereas approximately 4 patients in the control group reported recurrences for every 1 that did not. In years 2 3, the likelihood of reporting recurrences of LBP in the exercise group increased slightly to around 2:5, while the likelihood of recurrences in the control group reduced to 10:3. A repeat analysis of the data using the best case analysis revealed that patients in the control group were still 5.9 times more likely to suffer recurrences of LBP than patients in the specific exercise group in years 2 3 (x 2 (1) 5.92, P 0.015). Figure 1 shows the pattern of recurrence over time for each patient of the two groups. Figure 1(a) shows the control group patients recurrence patterns and 1(b) shows the specific exercise group patients recurrence patterns. Number and Severity of Recurrent Episodes For the first year, the mean number of episodes reported by those in the control group was compared with episodes on average for the specific exercise group. Recurrent episodes of LBP were rated as as se- Table 2. Risk of Recurrent Episodes of LBP and Confidence Limits for Each Group in Year 1 and Years 2 3 Year 1 Year 2 3 Risk 95% Confidence Limits Risk 95% Confidence Limits Exercise Control* * Less than 5 subjects in the control group reported no recurrences of LBP in both years.
4 E246 Spine Volume 26 Number exercise group reported persistent low level LBP that was subsequently aggravated by activities such as lifting. The number of specific episodes reported by the remaining patients in the two groups were similar (control group, mean episodes, specific exercise group, mean ). Recurrent episodes of LBP were rated as as severe as the original episode by 2 of 12 (17%) of the control group and 1 of 7 (14.2%) of the specific exercise group. Precipitating Factors At 1 year, a traumatic incident initialed the recurrences in 3 of 16 (19%) of the control group. These included bending and lifting (2 patients) and a trampoline accident. In contrast, 4 of 6 (67%) of the specific exercise group could relate traumatic incidences to recurrences. These included carrying a patient and slipping, heavy lifting (2 patients), and an incident that involved pulling a heavy sail on a boat. For years 2 3, a traumatic incident was related to recurrences in the preceding 2 years by 5 of 12 (42%) of the control group, and all (7 of 7) of the patients from the specific exercise group who experienced recurrences. The three patients in the specific exercise group who only reported episodes in years 2 3 related them to high-trauma incidents including a motor vehicle accident, a work-related heavy lifting incident, and an injury in representative level football. Apart from these cases, patients of both groups most commonly reported precipitating incidents related to lifting. Figure 1. Pattern of LBP recurrence over time for each patient of the two groups. A, Control group. B, specific exercise group. 16 of 19 (84%) of the control group reported recurrences in the first year after the acute episode compared with 6 of 20 (30%) of the specific exercise group. In years 2 3, of the 16 patients from the control group who had experienced recurrences in the first year, 2 were lost to follow-up. 12 of 14 (86%) of the control group patients who experienced recurrences in the first year reported continuing recurrences. For years 2 3 there were recurrences reported in 12 of 16 (75%). For the specific exercise group, of the 6 who experienced recurrences in the first year, 4 continued to have recurrences during years 2 and 3. Three subjects who had not experienced recurrences in the first year reported acute injuries during years 2 through 3, with 7 of 20 reporting recurrences in years 2 through 3. vere as the original episode by 9 of 16 (56%) of the control group and 2 of 6 (33%) of the specific exercise group. For years 2 3, of those who experienced recurrences, 5 of 12 of the control and 4 of 7 of the specific Treatment Sought In the first year, treatment was sought by 8 of 19 (42%) of the patients from the control group and 3 of 20 (15%) of the specific exercise group. In all cases, this treatment consisted of medical management (time off from work, advice, medications) and physiotherapy treatment. A variety of physiotherapy treatments were reported. However, the patients did not report that the treating physiotherapists had prescribed specific multifidus exercises. Contamination of the exercise outcome from the 1-year follow-up can therefore be considered minimal. For years 2 3, 4 of 16 (25%) of the control group sought treatment in the 2-year period in comparison with 4 of 20 (20%) of the specific exercise group. Control group patients accessed physiotherapy, medical management, and one had received an orthopedic consult, whereas patients from the specific exercise group received physiotherapy only. Patients Lost to Follow-Up The three patients who were lost to follow-up for years 2 3 reported quite different patterns of recurrence over the 1-year follow-up period. Patient 12, at 1 year, reported that recurrent episodes started within 2 4 weeks of the 10-week initial trial period. She had experienced several episodes. The aggravating factor was prolonged sitting (studying), after which she reported experiencing pain at night. She did not suffer any traumatic predisposing injuries to precipitate these recurrences, but reported
5 Stabilizing Exercises for Low Back Pain Hides et al E247 that they were milder than the original incident, for which she sought treatment. In contrast, patient 13 was one of the 16% from the control group who had not experienced any recurrences at the 1-year follow-up. After bending over to make a bed during the 1 year follow-up period, patient 19 experienced one 2-week episode of LBP as severe as the original incident, for which treatment was sought. This had resulted in time off work (2 days) but medications were not used. Discussion The results from the control group, who were managed medically and advised to resume normal activity, reflect the reported high recurrence rate of LBP that occurs after the initial episode. 3,35 37 Their recurrence rate at 1 year (84%) is similar to the rates previously reported and furthermore, for 56% of these subjects, the recurrences were reported as being as severe and disabling as the original episode. In contrast, the group to whom specific exercise was given to the multifidus reported only 30% recurrence at 1 year and these were reported as being as severe in only 33% of cases. Results from the control group lead us to agree with the report of Von Korff and Saunders 40 in that the course of LBP for most primary care patients is recurrent rather than acute or chronic in the usual sense of these terms. Furthermore, as expressed by Von Korff and Saunders, 40 it is necessary to assess not only the short-term outcome of the index episode but also the long-term outcomes over a sufficient period of time. The positive natural history of acute LBP in the short-term, without provision of long-term follow-up, may have led to an underestimation of the importance of early intervention, which aims to prevent recurrences. Results from the control group highlight that the greatest number of recurrences (especially severe disabling ones) occur predominantly in the first year after the original episode. Few detailed reports of long-term follow-up of acute LBP are available. The most detail for the year following the initial episode is provided by Bergquist-Ullman and Larsson. 3 However, little information is available for longer-term outcomes. Von Korff and Saunders 39 report that LBP recurrence rates were similarly high at follow-up at 2 years. In this study, recurrence rates remained high for the control group for years two to three (75%), but episodes reported as equally severe as the original episode decreased from 56% to 17%. This investigation therefore demonstrated some moderation in LBP over time, and it has been previously reported that the risk of recurrence lessens 2 years after an acute episode. 24 As the highest rate of severe disabling recurrences occurred in the first year after the initial episode and one of the major costs of LBP is in association with those who have recurrent disabling episodes of LBP, 12 it would appear that intervention may have its maximal benefits in this period. However, long-term positive effects of the intervention used were demonstrated in this study (30% recurrence at 1 year to 35% recurrence rate for years two to three). This long-term benefit was achieved with a short intervention period (4 weeks). There is now biomechanical evidence to explain the role of the multifidus in stabilization of the lumbar segments. 14,28,34,41 The rehabilitation approach aimed at retraining the multifidus for its functional role of protection and control of movements of the vertebral segments. 14,28,34,41 It is now possible to hypothesize how this approach may be effective to account for the longterm differences between the control and specific exercise groups. Following an acute injury to the low back, a deficit in the multifidus may leave the injured segment susceptible to further injury. Specific exercise therapy may be required to restore normal muscle function, with the long-term sequelae of a deficient multifidus in control subjects being a susceptibility to further injury and recurrence of LBP. Furthermore, the biomechanical model provided by Cholewicki and McGill 4 may help to explain why recurrences occurred with seemingly little provocation, especially in the control group subjects. The model highlighted the importance of muscles that provide spinal segmental support, not only during high demand activities such as heavy lifting, but during low load activity requiring only low muscle forces. Deficient stabilization of lumbar segments caused by a deficient multifidus may explain LBP recurrence with minimal or no predisposing incidents. This study provides one step forward in the knowledge concerning the long-term effects of conservative management for LBP patients. The results are promising in that they suggest that specific exercises help to reduce the high recurrence rate of LBP after the initial acute episode, and this pilot study may be used to determine a design model for further research. The limitations of this study include the small sample size and limited outcome measures (telephone questionnaire) for long-term follow-up. More evidence in a larger study population is required to further substantiate the findings of this study. Conclusion The results from this study showed that subjects with acute, first-episode LBP who received specific exercise therapy in addition to medical management and resumption of normal activity experienced fewer recurrences of LBP in the long-term than subjects who received only medical management and resumed normal activity. Biomechanical research may explain why it is important to focus on particular muscles for their stabilizing functions in rehabilitation. Additional research on larger subject populations is required, and other factors will obviously be involved in low back pain recurrence. However, in terms of prevention of recurrences, this study might represent one step forward in the optimal management of the acute low back pain patient.
6 E248 Spine Volume 26 Number Key Points Following an initial episode of acute low back pain (LBP), the recurrence rate is high. This randomized clinical trial followed acute low back pain patients who undertook specific stabilization exercises and control subjects for 3 years. Results showed decreased recurrence of low back pain episodes in the specific exercise group compared with the control group. Acknowledgments The authors thank the patients studied, Helen King for interviewing patients, the staff of the Mater Misericordiae Adult Hospital, Craig Shaw for statistical advice, Dr D.H. Cooper for helpful suggestions with this manuscript, The Menzies Foundation, The JP Kelly Mater Research Foundation, The Wenkart Foundation, The Physiotherapy Research Foundation, and the Manual Therapy Special Group (Australia) for financial support. References 1. Andersson GBJ, Svensson HO, Oden A. The intensity of work recovery in low back pain. Spine 1983;8: Baecke J, Burema J, Frejters J. A short questionnaire for the measurement of habitual activity in epidemiological studies. Am J Clin Nutr 1982;36: Bergquist-Ullman M, Larsson U. Acute low back pain in industry: a controlled prospective study with special reference to therapy and confounding factors. Acta Orthop Scand 1970;170(suppl):S Cholewicki J, McGill SM. Mechanical stability of the in vivo lumbar spine: implications for injury and low back pain. Clin Biomech 1996;11: Coste J, Delecoeuillerie G, et al. Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice. BMJ 1994;308(6928): De Leeuw ED, van der Zouwen J. Data quality in telephone and face to face surveys: a comparative meta-analysis. In Groves RM, ed. Telephone Survey Methodology. New York: John Wiley and Sons, 1988: Deyo RA. The role of the primary care physician in reducing work absenteeism and costs due to back pain. In: Deyo RA, ed. Occupational Back Pain. Philadephia: Hanley and Belfus, 1987: Dillane JB, Fry J, Kalton G. Acute back syndrome a study from general practice. BMJ 1966;2: Dixon AJ. Problems of progress on back pain research. Rheumatol Rehabil 1973;12: Evans C, Gilbert JR, Taylor DW, et al. A randomized controlled trial of flexion exercises, education and bed rest for patients with acute low back pain. Physiother Can 1987;39: Farrell JP, Twomey LT. Acute low back pain: comparison of two conservative treatment approaches. Med J Aust 1982;1: Frymoyer JW. Epidemiology. In: Frymoyer JW, Gordon SL, ed. New Perspectives in Low Back Pain. Illinois: American Academy of Othopaedic Surgeons, 1988: Frymoyer JW, Pope MH, Clements JH, et al. Risk factors in low back pain: an epidemiological study. J Bone Joint Surg [Am] 1983;65: Goel VK, Kong W, Han JS, et al. A combined finite element and optimization investigation of lumbar spine mechanics with and without muscles. Spine 1993;18: Hides JA, Stokes MJ, Saide M, et al. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine 1994;19: Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute first episode low back pain. Spine 1996;21: Hides JA, Richardson CA, Jull GA. Use of real-time ultrasound imaging for feedback in rehabilitation. Manual Therapy 1998;3: Jenkins EM, Borenstein DG. Exercise for the low back pain patient. Clin Rheumatol 1994;8: Jull GA, Richardson CA. Rehabilitation of active stabilization of the lumbar spine. In: Twomey LT, Taylor JR, eds. Physical Therapy of the Low Back, 2nd ed. New York: Churchill Livingstone, 1994: Kaigle AM, Holm SH, Hansson TH. Experimental instability in the lumbar spine. Spine 1995;20: Kelsey JL. Epidemiology of Musculoskeletal Disorders. New York: Oxford University Press, Lehmann TR, Spratt KF, et al. Predicting long-term disability in low back injured workers presenting to a spine consultant. Spine 1993;18: Morris A. Identifying workers at risk to back injury is not guesswork. Occup Health Saf 1985;55: Nachemson A. Advances in low back pain. Clin Orth 1985;200: O Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 1997;22: Panjabi M. The stabilizing system of the spine: Part I: Function, dysfunction, adaptation and enhancement. J Spinal Disord 1992a;5: Panjabi M. The stabilizing system of the spine. Part II: Neutral zone and instability hypothesis. J Spinal Disord 1992b;5: Panjabi M, Abumi K, Duranceau J, et al. Spinal stability and intersegmental muscle forces: a biomechanical model. Spine 1989;14: Rantanen J, Hurme M, Ralck B, et al. The lumbar multifidus muscle five years after surgery for a lumbar intervertebral disc herniation. Spine 1993; 18: Richardson CA, Jull GA. Muscle control pain control. What exercises would you prescribe? Manual Therapy 1995;1: Richardson CA, Jull GA, Hodges PW, et al. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain Churchill Livingstone: Edinburgh. 32. Sihvonen T, Herno A, Paljarvi L, et al. Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine 1993;18: Spengler DM, Bigos SJ, Martin NA, et al. Back injuries in industry: a retrospective study. I. Overview and cost analysis. Spine 1986;11: Steffen R, Nolte LP, Pingel TH. Rehabilitation of post-operative segmental lumbar instability. A biomechanical analysis of the rank of the back muscles. Rehabilitation 1994;33: Troup JD, Martin JW, Lloyd DC. Back pain in industry: a prospective survey. Spine 1981;6: Valkenberg HA, Haanen HCM. The epidemiology of low back pain. In White AA III, Gordon SL, eds. American Academy of Orthopaedic Surgeons Symposium on Idiopathic Low Back Pain. St. Louis: Mosby, 1982: Von Korff M, Deyo RA, Cherkin D, et al. Back pain in primary care: outcomes at one year. Spine 1993;18: Von Korff M, Dworkin SF, LeResche L. Graded classification of chronic pain: an epidemiologic evaluation. Pain 1990;40; Von Korff M, Ormel J, Keefe F, et al. Grading the severity of chronic pain. Pain 1992;50: Von Korff M, Saunders K. The course of back pain in primary care. Spine 1996;21: Wilke HJ, Wolf S, Claes LE, et al. Stability increase of the lumbar spine with different muscle groups: a biomechanical in vitro study. Spine 1995;20: Address reprint requests to Julie A. Hides Department of Physiotherapy Mater Misericordiae Adult Hospital Raymond Terrace South Brisbane, Queensland 4101 AUSTRALIA
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Welcome to ProfileBrand.com where we offer the largest variety of social networking layouts. Don't be fooled by the other layout sites offering sub par quality, we only have the best layouts for you. Whether it's default myspace layouts, 3.0 layouts, tumblr themes, 2.0 myspace layouts, friendster layouts, twitter backgrounds or even blogger templates, here at ProfileBrand.com we have you covered. Remember to bookmark us as we add layouts aswell as graphics daily, so you can always have a cool looking and updated profile.
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Roots Odutola: Models, keep pushing on
Upcoming model Roots Odutola urges other newcomers never to "relent".
The Nigerian fashion star joined the industry in 2011 and picked up the Dynamix Young Model of the Year and MTN Young Model of the Year Awards the following year.
Now she's looking forward to walking in New York Fashion Week and has shared her top tip for other young models hoping to get to where she is.
"To aspiring models, even when you get rejected, keep trying and don't relent," she advised in an interview with olisa.tv.
"Learn the basics and what works for you. Do not follow through with what others are doing because it seems like the right way to go. It is OK to be different. Most importantly, be urbane and let God Guide you!"
Roots isn't just a pretty face; she's also studying law and aspires to become a barrister and solicitor in the Supreme Court of Nigeria. She will keep her two jobs completely separate, but has used some of the prize money from her aforementioned model-of-the-year wins to fund her education.
It might seem like modelling would be the easier of the two careers, but it comes with its own challenges.
"It depends on a lot of things. For me, sometimes when I am walking, my legs come off my shoes because it's either too big or maybe the shoe does not fit. But, I do not let it bother me, I just continue walking. Thankfully, I have not slipped yet! Thank God!" she laughed.
Roots also revealed where she hopes her modelling will take her next. Among her jobs, she'd love to count the cover of iconic magazines Harper's Bazaar, Cosmopolitan, Glamour and Marie Claire.
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Author has written 34 stories for Sailor Moon, Fushigi Yuugi, Harry Potter, Dragon Ball Z, Gundam Wing/AC, Dance Dance Revolution, Inuyasha, Jem, Final Fantasy X, and Big Hero 6.
Hello people! I'm a heavy duty anime fanatic, manga consuming, computer game playing, & fun loving writer! And I'm really friendly! Here are my stats:
Name: Mina (if I let you call me that. :D)
Age: Twentysomething
Location: My REAL home is back in NY. Da Rock! (Far Rockaway, for those who dont know our lingo)
School status: GRADUATED! And awaiting stuff to do..LOL
Anime: (top favs out of MANY!) DBZ, Sailor Moon, Fushigi Yugi, I, My, Me! Strawberry Eggs, Pilot Candidate, Yu Yu Hakusho, Kare Kano (His & Her Circumstances), Sword Art Online &...more to come later!
Manga: Fushigi Yugi (Just got the LAST 1. #18!), Princess Ai (short but sweet!), Shojo Beat Manga magazine, Absolute boyfriend, Confidential Confessions (This an intense manga version of Degrassi: TNG) & a few others, but these are the ones I seriously collect!
TV: Daria, Degrassi (old school & TNG), Law & Order (ALL OF IT!! But please watch Los Angeles! I know we miss NY but if LOLA fails, the franchise may die!!) & lots of others..LOL
Movies: I'll get this list done when I have time!
A.N: As part of "No Words Needed, Usagi, I said a link of the ring will be here. Check it out
OMG!!!! I havent updated my profile in forever!! I just want to say thanks to everyone who continues to read my stories!! I dont always have time to write but I do check time to time on my old ones & I love the comments & positive feedback! I hope to have more stuff coming! Wishing you all lots of love, luck & happiness in the new year!!
Ok, it's be over a year since I wrote on my profile. Oh man...To be blunt, I've had Health issues from September 2006-April 2007, but thankfully I'm better & recovered from everything! I posted a new ficcie called "No Words Needed". It's sugar on top of a frosted vanilla cake, but hey, it's me. So I hope you guys enjoy that. It's not that I havent had inspiration, but I havent been in a writing mood until this morning thinking about stuff & I decided to let my fingers do the talking. Perhaps I'll have more luck over the course of the summer if no hurricanes dampen my mood. HAPPY (early) FOURTH OF JULY! Be safe & have great cook outs!
OMG! h!t has been crazy the last few months, hurricanes, schools, freaky quakes across the world...it seems the only time I ever get a break is to duck into the bathroom!
Anyway, I'll be done with school in September. In mid-July, I start clinic (basically working in a setting as practice) & hopefully when I'm done with all that, I can write. I havent had much inspiration for fanfics yet, but I do jot down some ideas & reread some of my fics to decide if I wanna continue or make new stories. You never know. Right now, I'm so hyped about turning 20 (July 3rd) & graduation even though the ceremony isnt until Jan/Feb 2007.
A lot of people like my Chichi/Goku fics, so I may write another one soon. Something different from the Cell surround plot lines. I've done 2 in different views & I think it's done without overcooking it with another one. I'll see! I have another Sailor Moon fic in mind, but as of now, it doesnt fit in with the Silver Millenniumish timeline. I'm working, dont worry! Hopefully I'll have time to write & post more than once every few months. I was rolling stone writing once & I will be again:laughs like Mandark: (Watch Dexter's Lab! I command it!)
-- MiNA 3
When you carry a Bible, the devil gets a headache. When you open it, he collapses. When he see's you reading it, he faints. When he sees you living it, he flees. And just when you're about to re-post this, he will try & discourage you. I just defeated him. Like, Copy, & Paste this if you're in God's Army :)


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Health Insurance
Our health is no doubt our top priority. Sudden accidents or illnesses are our biggest threat, both for us and for those we care about.
Although we can't protect you against them, we can make sure that, should anything happen, you will have the means to be treated in the best possible way, with Interasco Health insurance.
If you are a Greek resident, maintain your peace of mind by insuring yourself and your beloved ones with one of our major medical and personal accident insurance programs that best suit your needs. We will provide you with worldwide medical coverage and make sure that you receive the care you deserve.
You can also choose to have additional diagnostic coverage, that will help you prevent – rather than heal – health conditions at an early, mild stage.
Should you choose to insure with Interasco, our 24-hour health line will be at your entire disposal for anything to even distantly relates to your health status. Simply call 210 679 3200 and a expert team will assist you from scheduling your complimentary annual diagnostic check up till dealing with an emergency incident
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January 19, 2016
January 10, 2016
Registration for 2016 PedsCount! Summit Now Open! The 2016 PedsCount! Summit is headed to Long Beach, June 6 & 7, 2016.
January 8, 2016
The Transportation Research Board (TRB) 95th Annual Meeting will be held January 10–14, 2016, at the Walter E. Washington Convention Center, in Washington, D.C.
SafeTREC Frank Proulx will present "Estimating Bicycle Volumes Using a Combination of Disparate Data Sources" on Monday, Jan 11 at 10:45am.
December 21, 2015
Join Safe Routes to School on January 14, 2016 to learn about the new federal transportation bill and its impact on Safe Routes to School, Transportation Alternatives Program (TAP).
December 4, 2015
November 30, 2015
Save the date! The 2016 PedsCount! Summit is headed to Long Beach, June 6 & 7, 2016.
November 19, 2015
November 18, 2015
Lifesavers Conference: April 3-5, 2016
Learning Today, Leading Tomorrow
Date: April 3 - 5, 2016
Location: Long Beach Convention Center
300 E. Ocean Blvd, Long Beach CA 90802
November 4, 2015
November 3, 2015
November 2, 2015
October 30, 2015
October 27, 2015
Smart Growth America Webinar: The Economic & Fiscal Benefits of Walkable, Bikeable City and Town Centers
Friday, October 30, 2015 2:00 pm EDT
October 20, 2015
October 9, 2015
The Federal Highway Administration's (FHWA) new Separated Bike Lane Planning and Design Guide is an important resource for communities across the United States to use in building safe and connected bicycle networks that meet the needs of people of all ages and abilities.
October 6, 2015
Each year, using American Community Survey (ACS) data, the League of American Bicyclists reports on the state of bicycle commuting in cities across the country — and gives us a glimpse into how our community stacks up.
October 1, 2015
The 4th annual Sunday Streets Berkeley will convene on Sunday, October 18 between 11am and 4pm, with a focus on strolling, dancing and playing on Shattuck Avenue. Sunday Streets Berkeley travels along Shattuck Avenue for 17 blocks from Rose Street to Haste Street, filled with free activities for pedestrians of all ages!
September 30, 2015
September 25, 2015
Regular physical activity can improve our health and quality of life. However, many people across the United States do not get enough physical activity to realize these benefits. Promoting walking offers a powerful public health strategy to increase physical activity.


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US: Suitors are eyeing Pringles, says Procter & Gamble
Procter & Gamble has revealed Pringles is attracting "considerable interest" as potential buyer Diamond Foods deals with the fall-out of an accounting scandal that led to the departure of its CEO and CFO.
Diamond, which agreed a deal last April to buy Pringles, yesterday (8 February) announced that CEO Michael Mendes and CFO Steven Neil were on "administrative leave" after a company investigation found crop payments worth US$80m were not accounted for properly.
The probe was launched in November and had delayed Diamond's initial plans to buy Pringles by the end of the 2011. As the investigation was announced, Diamond and P&G said they expected the transaction to close by the end of June.
Although the deal has not been abandoned, in the wake of the probe the US consumer goods giant has been quick to emphasise that other suitors were eyeing Pringles.
"The information released by Diamond Foods is very disappointing. Pringles remains a valuable asset and it has attracted considerable interest from other outside parties. We need to evaluate next steps and we are currently keeping all our options open," Procter & Gamble said.
Speaking to just-food, a spokesperson for Procter & Gamble refused to be drawn on the identity of the mystery suitors.
He also declined to comment on how long Procter & Gamble's "evaluation" would take, or whether, ultimately, or not the deal would go through.
"We're focusing very much on keeping all our options open. I think it's wholly premature to discuss these things," he said.
Shares in Diamond, which will have to restate its financial results for 2010 and 2011, were down 37.08% at $23.07 at 10:17 ET.
Sectors: Financials, Mergers & acquisitions, Snacks
Companies: Pringles, Diamond Foods
Promo Tracker: Waitrose leads promo activity in June
Waitrose led the promotional activity in the UK grocery sector last month, according to the latest data from the just-food Promo Tracker....
US: Hostess Brands eyes bankruptcy exit despite jobs warning
US baker Hostess Brands, which filed for Chapter 11 protection earlier this year, has said it is still eyeing an exit from bankruptcy despite warning employees jobs could go if the company is sold or ...
US: Ex-Hostess Brands chief Driscoll named Diamond Foods CEO
Brian Driscoll, the former CEO of US baker Hostess Brands, which is in bankruptcy protection, has joined Diamond Foods as its chief executive....
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Taking Care of Business
Labor Day is an American federal holiday that is intended to pay tribute to the contributions and achievements of American workers. It also symbolizes the end of summer for many Americans, and for commercial real estate professionals the beginning of the frenzy to finish transactions before the end of the year.
These days market conditions are affording many office tenants the luxury of taking more time to make real estate decisions. While for me personally it has been a busy summer, transactions tend to move slowly as deal participants take their summer vacations and the "manana" mind-set is very much in play. Then Labor Day comes and go and magically everyone gets motivated to make decisions and execute the transactions they have been contemplating.
Today it seems office tenants have much more to consider when making real estate decisions as trends in the workplace have created a whole new set of decisions to be contemplated.This year happens to be an election year with a tight presidential race and uncertainty tends to make companies slower to make important business decisions.
However, rest assured that come Tuesday the pace of business will accelerate. You will be working longer hours and your cell phone will ring more, as the client who didn't call you back for three days this summer will be calling you daily for an update on the progress of their transaction. I am ready. Have a great Labor Day!


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We are the UK Government's independent adviser on sustainable development. Through advocacy, advice and
appraisal, we help put sustainable development at the heart of Government policy
SDC responds to Defra funding decision
22 July 2010
Will Day, Chair of the Sustainable Development Commission, today (Thursday 22 July) expressed his disappointment at Defra's announcement that it intends to withdraw its funding for the SDC from the next financial year, and paid tribute to the Commission's ten years of putting sustainability on the political map.
Will said: "We are deeply disappointed that the Government has announced its intention to withdraw its funding from the Sustainable Development Commission. Our work has delivered efficiency savings totalling many times what the organisation has cost the Government, and contributed towards much greater sustainability in Government – both in the way it runs itself, and the decisions it makes about our wellbeing and our future.
"The passion and commitment of our commissioners and staff has kept the SDC at the forefront of sustainable thinking. Our work has further benefited from the close collaboration of a wide range of partners over the years – from the Government Departments and Devolved Administrations with whom we have worked through issues of policy and practice; to the many organisations, professionals and individuals who have contributed their expertise and perspective. Though too many to list, their contribution has helped ensure the consistently high quality of the SDC's work.
"We note the commitment of the Secretaries of State for Defra and DECC to playing a lead role on sustainable development across Government. We await with interest the details of how a degree of cross-government independent scrutiny is to be achieved. However, what is important now is that the objectives we have championed – of properly balancing the needs of society, the economy and the environment as we respond to the pressing challenges ahead – find their way to the heart of all Government decision making.
"It will be particularly important to ensure that adequate plans are in place to ensure the UK Government can measure and verify its commitment to becoming the 'greenest government ever'. The SDC will be working hard with Government and the Devolved Administrations in the weeks ahead to make sure sustainable development is given an appropriate place, and that the legacy of our cutting edge advice and hands-on capability building continue to transform the UK for a bright future."
The announcement comes as the SDC publishes its fifth annual watchdog report on Government's progress towards more sustainable operations. The report concludes that moves towards greater sustainability made to date are saving government £60-70 million every year, and further progress has the potential to save hundreds of millions more.


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When it comes to "decision time" about which type of MySQL HA (high-availability) solution to implement, and how to architect the solution, many questions come to mind. The most important questions are:
- "What are the best tools to provide HA and Load Balancing?"
- "Should I be deploying this proxy tool on my application servers or on a standalone server?".
Ultimately, the best tool really depends on the needs of your application and your environment. You might already be using specific tools such as Consul or MHA, or you might be looking to implement tools that provide richer features. The dilemma of deploying a proxy instance per application host versus a standalone proxy instance is usually a trade-off between "a less effective load balancing algorithm" or "a single point of failure." Neither are desirable, but there are ways to implement a solution that balances all …[Read more]


text: It's been around for some time on the Google-backed Android platform, but now it looks like Google Goggles will be heading to the iPhone before the year is out.That's according to Google Goggles engineer David Petrou. According to The Register, he's quoted as saying: 'We're working on an iPhone version, and hope to have it out by the end of the year.' You can't be clearer than that.If it's the same app as the Android one, Google Goggles will allow you to search by taking a photo, Google's software doing the legwork in identifying landmarks and objects. Think of it as a travel courier without the constant chatter.Why the delay? Well, that's obvious really, different platforms require different coding, so Google is writing a new app from the ground up for iPhone users, something that takes time and a lot of testing.The app is still in its development stage even for Android, but already has a huge database to work with. There are approximately a billion images recognised, with a specific result on approximately 33 per cent of the queries it receives. It's certain to be popular when it lands in Apple's app store - and that should be very soon.


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Would you like to save as your currency permanently or for this visit only?
This guest did not leave comments about this hotel.
All there services were on point nothing to complain
Proximity to hospital Surroundings could be kept a bit cleaner, not only focus on the lobby (main entrance), there need to be a wider choice in breakfast menu
Close to Denny's restaurant.
The price
Easy check in and accommodations for early and later check out. Dirty pool
Dennys is a part of the restaurant. One machine in the exercise room was not working properly.
Next to stores There was one door that made so much noise getting into the building
close to freeway, close to dining establishments, room was very clean, staff was very nice, has jacquzzi and pool, also had breakfast which i missed
No pet policy. On website says you can pay extra but really there's a fine if you bring your pet in.Had to find someone to take care of him.
This guest did not leave comments about this hotel.
Nice pool area. The hotel is old but is in good repair. The staff is friendly and helpful. Denny's Diner and Rocky's Bar is part of hotel. Next to Freeway but rooms away from freeway side were quiet.
The hotel was very clean and well maintained. In the breakfast area, I suggest you do not have the TV tuned to the news channel. This includes CNN and MSNBC. It was unbearable to hear anti-American rants at 8 am. Who wants to listen to that at the start of their day. I suggest having a family channel on or something not so anti-American.
Breakfast very good with lots of choices. AC worked perfectly!
it was clean, friendly customer service The air conditioner in our room smelled weird
the staff was willing to help any hour of the day. They always were very polite. The elevator had no air which made it kind of sticky in there.
This guest did not leave comments about this hotel.
I like how beautifully furnished it was. The breakfast had a great assortment. Overall it was inviting.
The price per night we paid, and that it includes breakfast We had a small unexpected visitor on our wall
Location.the room was beautiful. The fridge didn't work. The coffee machine was very cheesy and the coffee bag they gave us barely fit in and soaked up half of the water. They asked if we wanted to switch rooms,but I was already completely unpacked.
price fairly new hotel...1st fl ice machine was out of order, so we had to go to 3rd fl for any ice...not a deal breaker, just inconvienent
Excellent service, friendly staff and a very happy go-lucky vibe.
Service was excellent. No lunch or dinner.
Great staff, centrally located, clean rooms, variety breakfast options, workout and up to date equipment, amazing overall!!! Stay was great!
Room was very nice and comfortable. Customer service lacked a bit of professionalism at the front desk. Blood stains and hair on towels. Only 1 out of three towels were properly clean. Windows need better sound proofing. Trains go through el centro all night long!
Bead was very comfortable, breakfast with lots of options I prefer inside pool specially in that area were it can get very windy.
This guest did not leave comments about this hotel.
The suite-style rooms are great, although probably a little big for one person for one night. If I was staying longer I would have really loved having a suite. Comfortable room. Friendly staff. Clean. Breakfast was sub-par, although I usually never expect much (if any at all). Elevator was really slow - not a big deal, but most of the time the stairs were faster for me.
Clean Pull out for my son touched the bed so impossible to get passed at night.
This guest did not leave comments about this hotel.
This guest did not leave comments about this hotel.
The staff! Rooms are very small. They offer a king bed with sofa bed, there was practically no room to open the sofabed. I'm glad we just stay one night, we barely could walk around the room.
This guest did not leave comments about this hotel.
Room was as advertised, no surprises. Very clean. Pool was closed
Very quiet, i was looking for something with a kitchenette and this one had everything i needed. The pool wasn't working, we were able to use the indoor one at their aister gotel next door but we wanted the outdoor pool experience.
This guest did not leave comments about this hotel.
Service, warm hospitality, & willingness to go the extra mile to accommodate.
Very roomy suite with all of the amenities.
This guest did not leave comments about this hotel.
Quiet place, need some upgrade but good for the money, clean Breakfeast included: Cofee cookies only
Wireless internet, many restaurants in neighbourhood, cheap hotel. Rooms were generally clean, but nog under the beds and tv desk there were tissues and a lot of dust.
this motel was not clean, carpet was torn, The wiring for the lamps was wierd, the TV was difficult to operate and the pool area was disgusting.
Friendly manager. Comfortable bed. Clean pool. (Brrr! (11 April)) Air con rattled something cruel. Luckily the tempuratue was fine during the night. Breakfast was a bit mean, coffee, orange juice, and a slice of cake. Nice cake. Need I mention the poor decor and musky smell at this price. PS. If the room shakes during your stay, its probably the tumble drier at the end of the block.
Old facilities, noisy area, continental breakfast was coffee, berry cake and apple but served late 7:30 AM
it was a cheap quick stay along my route. a no frills motel.
The staff seemed nice, mom and pop feel to it. Hookers, pimps, and all of the above. I walked down the street for some food, and I was harrased 2 times from the locals. There was doors slamimg, cars with loud music, not a place for a family with kids.
relaxing from high temp of 115
It was a very marginal inn even considering the price everything was old and worn out
The great air conditioner The internet didn't work, I had to use the internet down the street
At check in the staff was friendly and accommodated requests including extra towels. The staff was exceptionally helpful when we realized (after we had driven several hours away) that we had left our I pad at their hotel. The I pad is on its way to our home and we want to say THANK YOU to the staff!
The room was clean, the staff was very helpful and friendly. The pool was sparkling clean. Will stay there again next time I am in the area.
I liked that it was very easy to find, and there was no mandatory check in time...which is usually around 3. I got there at 11:00 am and they immediately gave me a room. We asked for 2 extra sheets of blankets and they didn't have any, there was also holes in the white linen sheets. The bath tub looked so dirty I had to shower with sandals on and to top it off the water wouldn't go down fast enough. But I guess for the price one can't complain.


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Posted by Mr. Boateng VERIFIED17 Aug 12:12 pmTema Metropolitan, Greater Accra
Sales officers and Marketing managers wanted for employment. salary will be both fixed plus commission plus allowances for transport and credit. interested persons should apply. send your application letters and CVs to the above Mail.
Stay safe!
Watch out for:


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'Salty' Aussie crocs go long-distance surfing: study
The world's biggest type of crocodile rides ocean currents for hundreds of miles (kilometres), effectively surfing to places way beyond its reach merely by swimming, a new study says.
Scientists were at a loss to explain how the estuarine or saltwater crocodile -- known as "salties" in Australia -- can be found across numerous South Pacific islands separated by huge expanses of water.
So the experts, including the late Australian television nature show presenter Steve Irwin, attached sonar transmitters to 27 adult specimens of the croc -- Latin name Crocodylus porosus -- to see exactly how they did it.
"The study demonstrates that C. porosus dramatically increase their travel potential by riding surface currents, providing an effective dispersal strategy for this species," added the researchers.
Specifically, the crocs -- the world's largest living reptile -- stayed near the surface when currents there were in the right direction, but dived deeper if flow direction became unfavourable."
The crocodile species can grow up to 20 feet (6.1 metres) in length. One 12.5 foot male travelled some 590 kilometres (367 miles) in 25 days, timing its journey to coincide with seasonal currents.
Another 16-footer covered more than 411 kilometres (255 miles) in just 20 days. Again, the crocodile utilised fast-moving ocean currents to reach its destination.
Hamish Campbell of the University of Queensland, said the C. posorus live in islands throughout the Indian and Pacific ocean.
"Because these crocodiles are poor swimmers, it is unlikely that they swim across vast tracts of ocean," he said of the study, published in Britain's Journal of Animal Ecology.
"But they can survive for long periods in salt-water without eating or drinking, so by only travelling when surface currents are favourable, they would be able to move long distances by sea.
"This not only helps to explains how estuarine crocodiles move between oceanic islands, but also contributes to the theory that crocodilians have crossed major marine barriers during their evolutionary past."


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Brackenfell is a Northern Suburb of Cape Town, located in the Western Cape. It is a well-known residential suburbia that forms part of the 'Boerewors Curtain' - a coined term that refers to the invisible 'divide' between Afrikaans and English people living in the city. Brackenfell was established in 1913, functioning as a major road crossing in Cape Town. Now, it is a residential area with beckoning views of the Oostenburg Mountain Range.
Not only do the picturesque vistas of mountains and distant vineyards attract visitors to the region, but its ideal location to the rural winelands makes it a holiday destination of choice for wine lovers. Brackenfell is a stone's throw away from The Durbanville Wine Valley Route, a ward of the Tygerberg Wine District that features a wide selection of wineries. Annually, aficionados look forward to the 'Feast of the Grape', a highly anticipated event that showcases award-winning wines from 12 of the valley's wineries. Event-goers have the opportunity to participate in activities such as grape-stomping and tutored wine tastings.
Surrounding attractions include the Bracken Nature Reserve, a quarry turned nature reserve that's home to the nearly-extinct Cape Flats Sand Fynbos and the Swartland Granite Renosterveld vegetation. The reserve harbours over 160 species of plants and flowers, which includes orchids, succulents and miscellaneous flowering bulbs. While vegetation is prevalent in the reserve, visitors can also spot a wide-spectrum of small mammals, reptiles, birds and amphibians.
If culture is what you're looking for, the Barnyard Theatre Willowbridge is some 5 km's away from Brackenfell. Being the only Barnyard Theatre in Cape Town and surrounds, avid theatre goers travel from far for rock shows, revues and musicals. Audience members will be able to relax the night away with some uproarious entertainment as well as being treated to a gourmet dinner prepared by highly-acclaimed chefs,
If you're looking for a day out in the wine valleys or some night-time entertainment, Brackenfell has a lot to offer holidaymakers. Book a weekend away at Brackenfell's various Bed n Breakfasts, or self-catering apartments.
Patrick Masungwini won a booking to the value of R1520 at The Vinelands on Alpha
I would like to thank Sleeping-OUT for selecting me as a prize winner.The website is excellent and I advise everyone to try it for their holiday bookings.
How can you Win Free Accommodation?
From R400* unit
We offer secure, self-catering units that is conveniently situated within walking distance from shops and restaurants Our units have private entrances with secure parking. De Oude Rus is near to Tyger... Read More
From R300 pps
The Vinelands on Alpha is a traditional old Cape Dutch style house. Nestled in a quiet suburb of Brackenfell, Western Cape, guests can experience the peace and tranquility of country living.
The gu... Read More
From R350 pps
Situated in Morgenster Heights, Brackenfell, you are invited to experience the peaceful countryside atmosphere of this Northern Suburb of Cape Town.
We offer five spacious, fully equipped self-cat... Read More
From R350* unit
Stay in comfort and luxury in a central location with easy and nearby access to all tourist attractions of the Cape Peninsula and Boland. We are situated on the Cape's wonderful wine route and only 20... Read More
From R550 pps
Morgenzicht offers a friendly homely atmosphere and is situated in a quiet and peaceful residential area of Morgenster Heights, Brackenfell.
Within easy reach of major highways, Cape Town city bo... Read More
From R425 pps
Open-plan, newly renovated, furnished, upmarket self-catering cottage (sleeps 2) in prime & quiet neighbourhood, Vredekloof (Brackenfell / Durbanville Western Cape). 24-hour security includes parking.... Read More
From R400 pps
Protea Retreat self catering apartment is set against the backdrop of the Protea Heights hills & the Cape Winelands & wine route. This luxury apartment, or chalet, call it whatever you wish, is a comp... Read More
From R900* unit
We are situated on a large 5 000 m² property. We have a large secure garden and lots of parking inside a remote controlled property.
We are situated in a very quiet and peaceful part of town and... Read More
From R297 pps
Bottelary Inn is situated in a upmarket residential area of Protea Heights Brackenfell . The accommodation consists of a beautiful big 3 bedroom cottage with 2 bathrooms that accommodates up to 11 per... Read More
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Situated in a tranquil suburb of Brackenfell, Yorkshire Guest House, a B&B of distinction and style awaits you.Yorkshire Guest House is only minutes away from the heart of Brackenfell business and mal... Read More
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In order to provide meaningful price comparisons this website compares the Per Person Sharing Rate or, where this is not available, the Average Price Per Person for a unit, based on its maximum occupancy.When Homes and Villas are selected as the search criteria, the full daily rate for the unit is used for price comparison and display irrespective of the number of people the unit sleeps.* This accommodation is only available as a unit. It has been included in these search results as the average price per person based on maximum occupancy falls within the selected price range. However, the price displayed is the full unit price.
Northern Suburbs (CPT)
Brackenfell Accommodation has been rated 4.5/5 based on 52 reviews.
BrackenfellSo many things to do and see! - Simone De Jager
BrackenfellIt was a great location, considering the travel distance to malls, service stations and nearby neighborhoods. - Fergus Bailey
BrackenfellSafe neighbourhood and a walking distance to the shops - Lebogang Mahlasela
BrackenfellBrackenfell is a quiet suburb. - Stephanie Buss
BrackenfellCentrally located so nothing is a major drive. Great for a short break where you go somewhere specific each day. - Marcus Carter