Pain and motor control of the lumbopelvic region: effect and possible mechanisms

doi:10.1016/S1050-6411(03)00042-7

Journal of Electromyography and Kinesiology

Volume 13, Issue 4, August 2003, Pages 361-370

https://doi.org/10.1016/S1050-6411(03)00042-7 Get rights and content

Abstract

Many authors report changes in the control of the trunk muscles in people with low back pain (LBP). Although there is considerable disagreement regarding the nature of these changes, we have consistently found differential effects on the deep intrinsic and superficial muscles of the lumbopelvic region. Two issues require consideration; first, the potential mechanisms for these changes in control, and secondly, the effect or outcome of changes in control for lumbopelvic function. Recent data indicate that experimentally induced pain may replicate some of the changes identified in people with LBP. While this does not exclude the possibility that changes in control of the trunk muscles may lead to pain, it does argue that, at least in some cases, pain may cause the changes in control. There are many possible mechanisms, including changes in excitability in the motor pathway, changes in the sensory system, and factors associated with the attention demanding, stressful and fearful aspects of pain. A new hypothesis is presented regarding the outcome from differential effects of pain on the elements of the motor system. Taken together these data argue for strategies of prevention and rehabilitation of LBP

Introduction

Changes in motor control and function of the trunk muscles have been reported frequently in the literature. These changes range from changes in recruitment to reduced strength and endurance of the trunk muscles. Notably, patterns of hyperactivity and hypoactivity have been reported and a variety of hypotheses have been developed to explain the effects and mechanisms of the changes. The majority of available hypotheses are broadly consistent with two main theories that propose; (i) that changes in muscle activity cause spinal pain (muscle–tension or pain–spasm–pain model), or (ii) changes in muscle activity serve to restrict spinal motion (pain adaptation model). Experimental (e.g. [11], [70], [95], [113]), and clinical [7], [50] data suggest that the muscle tension model is too simplistic, and offer support for the pain adaptation model [63], however considerable debate exists [114]. The purpose of this paper is to review the evidence for changes in motor control, discuss possible mechanisms for these changes and the effect of these changes on function of the lumbopelvic region.

Section snippets

Changes in motor control of the lumbopelvic region

Although early studies of trunk muscle function focused on the strength and endurance of the trunk muscles in patients with LBP (e.g. [94], [101]), more recently the focus has shifted to issues of motor control. The challenge of motor control of the lumbopelvic region is immense and must serve to move and control the spine in a range of environments and with a complex interaction between internal and external forces. The challenge is further complicated by the fact that without muscle the spine

Possible mechanisms for pain to affect motor control of the trunk muscles

It is not certain whether pain causes changes in motor control or whether motor control changes lead to pain, or both. Farfan [25] and Panjabi [77], amongst others, have presented models that suggest that deficits in motor control lead to poor control of joint movement, repeated microtrauma and pain. Consistent with this model, Janda [53] has argued that people who have mild neurological signs (e.g. minor coordination difficulties) are more likely to have pain as adults. Furthermore slow

Possible outcomes of motor control changes

In view of the differential changes in the deep intrinsic muscles and the superficial muscles in the presence of pain, it is critical to consider possible sequelae of these changes. All trunk muscles are required for control and stability of the spine [77] and it is clear that stability is dependent on the interplay between an array of muscles, both intrinsic and superficial [5], [14], [115]. Yet, there is considerable redundancy in the motor system with many muscles potentially able to perform

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Association of Pain-Related Anxiety and Abdominal Muscle Thickness during Standing Postural Tasks in Patients with Non-Specific Chronic Low Back Pain
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The purpose of this study was to evaluate the association of pain-related anxiety on abdominal muscles thickness during standing postural tasks among individuals with chronic low back pain (CLBP).
We obtained responses to a pain-related anxiety symptoms questionnaire from 50 participants with CLBP. We then separated participants into high (11 men, 14 women) and low pain-related anxiety (13 men, 12 women) groups and compared assessments of their lateral abdominal muscles thickness during standing tasks on a computerized balance assessment device, using one static level and 2 movable levels (levels 6 and 3 are represented easy and difficult tasks respectively).
We found a significant interaction effect of standing difficulty (2 levels) and abdominal muscle thickness (transverse abdominis, oblique internal and oblique external muscles) (p< .001, effect size= .7). The high pain-related anxiety group exhibited greater abdominal muscle thickness during standing postural tasks compared with the low pain-related anxiety group (p< .05, mean difference= .04-.06) except for the internal oblique muscle during the difficult standing task (p=.2).
We suggest that, among individuals with CLBP, pain-related anxiety and psychological pain-related anxiety may be possibly associated with abdominal muscles thickness during dynamic standing.
Increased velocity feedback gains in the presence of sensory noise can explain paradoxical changes in trunk motor control related to back pain
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Literature reports paradoxical findings regarding effects of low-back pain (LBP) on trunk motor control. Compared to healthy individuals, patients with LBP, especially those with high pain-related anxiety, showed stronger trunk extensor reflexes and more resistance against perturbations. On the other hand, LBP patients and especially those with high pain-related anxiety showed decreased precision in unperturbed trunk movement and posture. These paradoxical effects might be explained by arousal potentially increasing average and variance of muscle spindle firing rates. Increased average firing rates could increase resistance against perturbations, but increased variance could decrease precision. We performed a simulation study to test this hypothesis.
We modeled the trunk as a 2D inverted pendulum, stabilized by two antagonistic Hill-type muscles, based on their open-loop muscle activation dependent intrinsic stiffness and damping and through 25 ms-delayed, noisy contractile element length and velocity feedback. Reference feedback gains and sensory noise levels were tuned based on previously reported experimental data. We assessed the effect of increasing feedback gains on precision of trunk orientation at different perturbation magnitudes and assessed sensitivity of the effects to open-loop muscle stimulation and noise levels.
At low perturbation magnitudes, increasing reflex gains consistently caused an increase in the variance of trunk orientation. At larger perturbation magnitudes, increasing reflex gains consistently caused a decrease in the variance of trunk orientation.
Our results support the notion that LBP and related anxiety may increase reflex gains, resulting in an increase in the average and variance of spindle afference, which in turn increase resistance against perturbations and decrease movement precision.
Knee joint repositioning error in different trunk positions among females with chronic nonspecific low back pain: A cross-sectional study
2023, Journal of Bodywork and Movement Therapies
Proprioception is a self-perceived sense of position and movement of one's body and its deficits can lead to motor control problems such as delayed muscle reflexes. Previous studies have confirmed lumbar proprioception impairments among individuals with Low Back Pain (LBP), which can afflict the normal central sensory-motor control and hence increases the risk of abnormal loading on the lumbar spine. Although the local investigation of proprioception is important, its influence on other joints in a kinetic chain particularly between extremities and spine should not be ignored. Therefore, the aim of this study was to compare the proprioception of knee joint in different trunk positions among females with chronic nonspecific low back pain (CNSLBP) and healthy females.
The study included 24 healthy subjects and 25 patients with CNSLBP participated in this study. Repositioning error of knee joint in four different lumbar positions including flexion, neutral position, 50% ROM of left rotation and 50% ROM right rotation was evaluated using an inclinometer. Absolute error and constant error were obtained and analyzed.
Absolute error in flexion and neutral positions in the individuals with CNSLBP were significantly higher than in healthy individuals; whereas, there was no significant difference in absolute and constant error between the two groups in 50% rotation to either side.
This study showed that knee joint repositioning accuracy was reduced in patients with CNSLBP compared to healthy ones.
Effects of spinal segmental flexion and extension exercises on spinal flexibility
2023, Journal of Bodywork and Movement Therapies
We considered spinal segmental movement exercise that voluntarily control local muscles as a convenient treatment to correct the trunk muscle recruitment pattern in individuals with global muscle overactivity. The purpose of this study was to verify the effects of segmental flexion and extension movements of the spine and overall flexion and extension movements of the spinal column on the flexibility of the spinal column among healthy university students who had completed a day of lectures and had a certain load on their lower back as a preliminary step to applying the exercise to low back pain patients with a broken trunk muscle recruitment pattern.
The subjects performed trunk flexion/extension exercises that required segmental control of the spine (segmental movement) and trunk flexion/extension exercises that do not require segmental control of the spine (total movement) in the chair position. As an evaluation task, finger floor distance (FFD) and muscle tension of the hamstrings were evaluated before and after exercise intervention.
There was no significant difference in the FFD value and the passive pressure before the intervention between the two exercises. FFD decreased significantly after the intervention compared to that before, and passive pressure did not change in both motor tasks. The FFD change amount of segmental movement was significantly larger than that of total movement. (P < 0.01).
It has been suggested that segmental spinal movements improve spinal mobility and may reduce global muscle tension.
In non-specific low back pain, is an exercise program carried out through telerehabilitation as effective as one carried out in a physiotherapy center? A controlled randomized trial
2023, Musculoskeletal Science and Practice
s:The effectiveness of telerehabilitation (TLRH) in patients with non-specific low back pain (NLBP) remains unknown. No study till date has investigated the efficacy of a mobile-based TLRH in patients with NLBP.
To investigate if a TLRH program is as effective as a clinical exercise programme in improving disability, pain intensity, pain catastrophizing, and hip pain and strength in patients with NLBP.
Single-blind, two-armed, randomized controlled study.
A total of 71 individuals with NLBP were randomly allocated to either the TLRH home group (TLRH) or clinic group (CG). The TLRH followed exercise videos and read information on pain neurophysiology. The CG performed the same exercises and received on-site pain education. Both groups performed the exercises twice weekly for 8 weeks. Disability, pain intensity, pain catastrophizing, and hip pain and strength were assessed at baseline, at post-treatment, and at three months.
Statistically significant differences for time-by-group interaction were detected in the strength of left hip flexors (supine [F = 8.356; p = .005]; sitting [F = 9.828; p = .003]), right hip extensors with extended knee [F = 7.461; p = .008], left hip extensors (extended knee [F = 13.175; p = .001]; flexed knee [F = 13.505; p < .001]), pain during flexion of the right [F = 5.133; p = .027] and left [F = 4.731; p = .033] hips in the supine position, disability [F = 4.557; p = .014], and pain catastrophizing [F = 14.132; p < .001].
A TLRH mobile-based is as effective as clinical treatment in improving disability, pain catastrophizing, and pain and strength of the hip structures in patients with NLBP.
The dynamic postural steadiness and stabilization time between older adults with and without recurrent low back pain
2023, Gait and Posture
Although postural control measures were reported to identify neuromuscular impairments, postural steadiness and stabilization time were not carefully investigated between subjects with and without recurrent low back pain (LBP).
Research QuestionAre there group differences in the stabilization time, direction of sway, and dynamic postural steadiness index (DPSI) during one-leg standing?
Thirty-four control subjects and 29 subjects with recurrent LBP participated in the study. Each subject stood upright on a single leg with and without visual input. The outcomes were measured for standing duration (sec), direction of sway, and the DPSI, which included the vertical steadiness index (VSI). The VSI assesses fluctuations to standardize the vertical ground reaction forces on the force plate.
The control group demonstrated significantly longer standing duration compared to the LBP group during the eyes-open condition (t = 3.55, p = 0.001). The LBP group demonstrated significantly faster stabilization time (t = 2.53, p = 0.01) in the sagittal plane. The DPSI demonstrated an excellent relationship with the VSI without visual input in the control group (r = 0.98, p = 0.001). The directions of sway demonstrated a significant interaction between groups (F = 9.29, p = 0.004).
Although standing duration in the eyes-open condition decreased in the LBP group, a faster stabilization time in the sagittal plane was evident compared to the control group to adapt postural stability. These results indicated that vertical dynamic steadiness with visual input might be important to enhance compensatory postural control.

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Paul Hodges is an NHMRC Senior Research Fellow and Associate Professor at the University of Queensland where he heads the Human Neuroscience Unit. Paul’s research involves integration of neuroscience and biomechanics to investigate the nervous system control of joint stability and movement. Key areas of research include investigation of: task conflict of the trunk muscles, in vivo and in vitro studies of the biomechanical effect of contraction of intrinsic spinal muscles on the spine, mechanisms for pain to affect motor control, strategies used by the central nervous system to control joint stability, and the mechanism of efficacy of therapeutic exercise for musculoskeletal pain. In addition to his research in Brisbane, Paul has ongoing collaborations with laboratories in Sydney, Stockholm (Sweden), and Portland (USA). He has published more than 50 research papers in international physiology and medical journals, has presented more than 15 keynote lectures at International back pain and motor control conferences in Australia, Europe and North America and has co-authored a clinical text. Paul’s research has resulted in several awards from the Australian Society for Medical Research and the International Society for Biomechanics and led to him being awarded the Young Australian of the Year Award for Science and Technology for 1997.

Lorimer Moseley completed his Ph.D. at the Pain Management and Research Centre, University of Sydney, where he investigated the psychophysiology of pain and spinal control. He has also conducted several clinical trials into the use of high level pain physiology education as a therapeutic strategy. Lorimer is an Australian NHMRC Clinical Research Fellow currently researching perceptual and motor mechanisms of pain at Royal Brisbane Hospital and The University of Queensland. His particular interests are the interface between physiotherapy, psychology and physiology; conceptual paradigms of pain; and therapeutic strategies for the integration of pain sciences and clinical practice, particularly for those with chronic and recurrent pain.

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Pain and motor control of the lumbopelvic region: effect and possible mechanisms

Abstract

Introduction

Section snippets

Changes in motor control of the lumbopelvic region

Possible mechanisms for pain to affect motor control of the trunk muscles

Possible outcomes of motor control changes

Electromyographic recordings of 5 types of low back pain subjects and non-pain controls in different positions

Pain

The influence of low back pain on muscle activity and coordination during gait: a clinical and experimental study

Pain

Directional specificity of postural muscles in feed-forward postural reactions during fast voluntary arm movements

Experimental Brain Research

Elements of control of voluntary movements

Biofizika

Stability of the lumbar spine. A study in mechanical engineering

Acta Orthopedica Scandinavica

Power spectrum analysis of electromyographic activity: discriminators in the differential assessment of patients with chronic low back pain

Spine

Variation in meaning of pain descriptors for different headache types as revealed by psychophysical scaling

Headache

A sequence of postural adjustments precedes voluntary movement

Neuroscience Letters

The role of paraspinal muscle spindles in lumbosacral position sense in individuals with and without low back pain

Spine

Variations in balance and body sway in middle-aged adults: subjects with healthy backs compared with subjects with low back dysfunction

Spine

Experimental muscle pain produces central modulation of proprioceptive signals arising from jaw muscle spindles

Pain

The effects of muscle fatigue on shoulder joint position sense

American Journal of Sports Medicine

Stabilizing function of trunk flexor–extensor muscles around a neutral spine posture

Spine

Relative contribution of trunk muscles to the stability of the lumbar spine during isometric exertions

Clinical Biomechanics

Comparative analysis of paraspinal and frontalis emg, heart rate and skin conductance in chronic low back pain patients and normals to various postures and stresses

Scandinavian Journal of Rehabilitation Medicine

Emg scanning in the diagnosis of chronic pain

Biofeedback and Self Regulation

Observations on intra-abdominal pressure and patterns of abdominal intra-muscular activity in man

Acta Physiologica Scandinavica

Attentional disruption is enhanced by the threat of pain

Behavioural Research and Therapy

Attention to chronic pain is dependent upon pain-related fear

Journal of Psychosomatic Research

Pain processing during three levels of noxious stimulation produces differential patterns of central activity

Pain

Functional anatomy of the respiratory muscles

Pain demands attention: a cognitive–affective model of the interruptive function of pain

Psychological Bulletin

Psychological stress and muscle activity during data entry at visual display units

Work Stress

On reflex effects from knee joint of cats

Acta Physiologica Scandinavica

Mechanical disorders of the low back

Symptom-specific psychophysiological responses in chronic pain patients

Psychophysiology

Extensive reorganization of primary somatosensory cortex in chronic back pain patients

Neuroscience Letters

Psychophysiology of chronic pain: do chronic pain patients exhibit symptom-specific psychophysiological responses?

Psychological Bulletin

Supraspinal factors in human muscle fatigue: evidence for suboptimal output from the motor cortex

Journal of Physiology (London)

Kinaesthetic signals and muscle contraction

Trends in Neurosciences

The effects of abdominal muscle coactivation on lumbar spine stability

Spine

The measurement of lumbar proprioception in individuals with and without low back pain

Spine

Effects of experimental muscle pain on muscle activity and coordination during static and dynamic motor function

Electroencephalography and Clinical Neurophysiology

The mechanisms of postural regulation in man

Soviet Scientific Reviews. Section F. Physiology and general biology

Postural responses in persons with low back pain

Long term effects of specific stabilizing exercises for first episode low back pain

Spine

Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain

Spine

Changes in motor planning of feedforward postural responses of the trunk muscles in low back pain

Experimental Brain Research