motor control of the spine in acute, recurrent and chronic ... · impairments, adaptations, and...

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Motor Control of the Spine in Acute, Recurrent and Chronic LBP:

Impairments, Adaptations, and Clinical Applications

George J Beneck, PhD, PT, OCS Jo Armour Smith, PT, MManTher, OCS

PHYSICAL FACTORS

Delitto et al., JOSPT, 2012

DEMOGRAPHIC FACTORS

WORK/LEISURE ACTIVITY

PSYCHOSOCIAL FACTORS

INDIVIDUAL WITH LOW BACK PAIN

ANTHROPOMETRIC FACTORS

• The production of coordinated movement

• Interaction between the individual, task and environment

• Multiple systems and processes

What is motor control?

Shumway Cook & Woollacott., 2007

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• Musculoskeletal system

• Central nervous system

• Sensory/perceptual processes

• Cognitive processes

What is motor control?

Individual muscle systems

How may motor control be altered?

• Amplitude of muscle activity

• Timing of muscle activity

• Muscle co-contraction

• Adaptability of muscle activation

Altered motion

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How may motor control be altered?

• Adaptability = variability

• Some variability is associated with stable performance of a task

• Allows individual to achieve task under changing environmental conditions and task constraints

• Altered variability is associated with ageing and some musculoskeletal disorders

How may motor control be adapted?

PAIN

SPASM ISCHEMIA

PAIN

AGONIST ANTAGONIST

• Some consistent adaptations across individuals • Some inconsistent adaptations between individuals • Complex due to redundancy of trunk muscle system

Motor control and low back pain

Delitto et al., JOSPT, 2012

ACUTE/SUB-ACUTE LBP

RECURRENT LBP

RECURRENT LBP

RECURRENT LBP

CHRONIC LBP

TIME

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INDIVIDUAL MUSCLE SYSTEMS INTEGRATED SPINAL CONTROL

Healthy, Young, Fit Lumbar Muscle

L5-S1 L5

L4-L5

L3-L4

Psoas

Multifidus

Erector

Spinae

Physiologic PCSA: Multifidus

25

0

10

5

5 15 10 20 25 30 Fiber Length (cm)

Phy

sio

logi

c C

ross

Sec

tio

nal

Are

a (

cm2)

------- Increasing Excursion------->

----

---

Incr

easi

ng

Forc

e---

----

>

Rectus Abdominis

Longissimus Thoracic

Iliocostalis Lumborum

Multifidus

15

20

30

Ward et al, JBJS, 2009 Delp et al, J Biomech, 2001

Quadratus Lumborum

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Length-Tension Curve: Multifidus

80%

60%

1.0

40%

20%

1.5 2.5 2.0 3.0 3.5 4.0 Sarcomere Length (µm)

Rel

ativ

e Te

nsi

on

(%

P0)

100%

Neutral

Flexed

Ward et al, JBJS, 2009

Morphologic Changes with LBP

Cause and Progression?

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Atrophy & Fat Replacement

• When? – Acute? – Subacute? – Chronic?

• Where? – Generalized? – Unilateral or bilateral? – 1 segments? 5 segments?

• Why? – Reflex inhibition? – Deconditioning? – Denervation? – Aging? – Surgical procedures?


• Acute unilateral LBP – mean symptom duration: 13 days

– Atrophy at painful side and segment

• 31% reduced cross-sectional area (CSA) - unilateral

Hides et al, Spine, 1994 Ultrasound Images

Hides et al, JOSPT, 2008


Early Chronic Unilateral LBP (Ave: 3 months)

– Painful side and segment: 21% reduced CSA

Barker et al, Spine, 2004

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Chronic LBP - Fat infiltration common

Mengiardi et al, Radiol, 2006 Parkkola et al, Spine, 1993

Volumetric Measurements

Image segmentation: L4 inferior endplate to S1 inferior endplate

Muscle Volume =

CSA x slice thickness (5 mm) x # slices

Beneck & Kulig, APM&R, 2012

L5-S1 Multifidus Volume

18.1% reduced, bilaterally

No Pain

Side

Matched

No Pain

Side

Pain

Side

Matched

Pain Side


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L4 Multifidus Volume

N = 26

No Pain

Side

No Pain

Side

Matched

No Pain

Side

Pain

Side

Matched

Pain Side


S2-S3 Multifidus Volume

No Pain

Side No Pain

Side

Matched No Pain Side

Pain Side

Matched Pain Side


L5-S1 Erector Spinae Volume


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Muscle Morphology and Back Pain

• Sample Case and Control: Unilateral Low Back Pain – Pain/injury cause of

atrophy? – Local multifidus atrophy?

Healthy

CLBP

Lumbar Multifidus

Series of overlapping bands and fascicles

Spanning 2-5 segments

Attaching to each of the 5 lumbar vertebrae

Prospective Validation Study

Hodges et al, Spine, 2006

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Prospective Validation Study

Atrophy of deep fibers? Intervertebral Disc

Fat Infiltration

Multifidus

Campbell et al, Muscle & Nerve, 1998 Kader et al, Clin Radiol, 2000 Hodges et al, Spine, 2006

Deep Fibers = Short Fibers

Multifidus Atrophy Localized to Painful Region

L5

L5

T12 T12

Healthy: matched for age, size and activity

Low Back Pain

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Back Extensor Fatigability

• Low Endurance

–Associated with LBP1-5

–A Risk Factor for LBP6-8

Sorensen test: max holding time

1. Crossman, Spine, 2004 2. Nourbakhsh, JOSPT, 2002 3. Mannion, J Rehab Res & Dev, 1997 4. Tsuboi, Appl Physiol Occup Physiol, 1994 5. Nicolaisen, Scand J Rehab Med, 1985 6. Adams, Spine, 1999 7. Alaranta, Clin Biomech, 1995 8. Biering-Sorensen, Spine, 1984

Back Extensor Endurance

• Sorensen Test Limitations

– 37% stopped for reasons other than fatigue1

• EMG fatigue testing

Hz 50 100 150 200 250 300 350 400 450 500

300 250 200 150 100 50

Power Spectral Analysis

Ropponen et al, JOSPT, 2005

MF Slope

• The median frequencies are plotted over time. • The slope is the best-fit line of the median

frequencies.

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30 Second Hold

-0.70

-0.60

-0.50

-0.40

-0.30

-0.20

-0.10

0.00

No

rmali

zed

Med

ian

Fre

qu

en

cy S

lop

e,

Mean

(S

EM

)

P=0.650

Deep Multifidus

Superficial Multifidus

Thoracic Longissimus

Lumbar Longissimus

Beneck et al, J Electromyogr Kinesiol, 2013

Results – Low Back Pain

-0.70

-0.60

-0.50

-0.40

-0.30

-0.20

-0.10

0.00

No

rmal

ized

Med

ian

Fre

qu

ency

Sl

op

e, M

ean

(SE

M)

Deep Multifidus

Superficial Multifidus

Thoracic Longissimus

Lumbar Longissimus

P=0.013 Simple Contrasts

P=0.135

P=0.114

DM vs TES

SM vs TES

LES vs TES

First 30 sec

Last 30 sec

* * * * * * *

*

P=0.008 Main Effect, Time P=0.027 Interaction, Time x Muscle


Slope Change: Deep Multifidus

Time (sec)

0 - 30 0 - 30

Time (sec)

100 100

Rela

tive c

han

ge

Rela

tive c

han

ge

CLBP Healthy


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Curvilinear Behavior – High Demand

Feline Multifidus: Reflex Activation1

Human Tibialis Anterior2

80% MVIC

High Intensity Stimulation

Less Demand

1. Arabadzhiev et al, Eur J Appl Physiol, 2008 2. Merletti et al, J Appl Physiol, 2008

Rel

ativ

e ch

ange

(%

)

Explanation?

• Rapid drop out of type II motor units in deep multifidus

• Selective atrophy of fast fibers in persons with LBP1-5

CLBP: Deep Multifidus

1. Fidler, JBJS, 1975 2. Kalimo, Ann Med, 1989 3. Mattila, Spine, 1986 4. Rantanen, Spine, 1993 5. Zhu, Spine, 1989

Activation

• Delayed Activation (Timing) – Sudden load1 – Load release2 – Arm movements3, 4

1. Magnussen et al, Eur Spine J. 1996 2. Radebold et al, Spine, 2001 3. Silfies et al, APM&R, 2009 4. Hodges et al, J Spinal Disorders, 1998

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Influence of Anticipation on Activation

• Self-initiated

–Rapid Arm Movements1

• Feedforward activation – deep fibers only

– Loading2

• Earlier activation

• Feedforward activation – deep fibers only

1. Moseley & Hodges, Spine, 2002 2. Moseley et al, J Physiol, 2003

Impaired Activation with Recurrent LBP

• Rapid Arm Movements1 – Onset time delayed (20 ms) only

in deep fibers on side of LBP

• Loading Response – Anticipation did not result in

earlier activation in patients with disc herniation2

– Bilateral reduction in amplitudes in deep fibers prior to load release with unilateral LBP3.

1. MacDonald et al, Pain, 2009 2. Leinonen et al, Spine, 2001 3. MacDonald et al, Spine, 2010

Physiologic PCSA: Psoas

25

0

10

5

5 15 10 20 25 30 Fiber Length (cm)

Physio

log

ic C

ross S

ectional A

rea

(cm

2) ------- Increasing Excursion------->

----

---

Incre

asin

g F

orc

e--

----

->

Rectus

Abdominis

Longissimus

Thoracic

Iliocostalis

Lumborum

Multifidus

15

20

30

Quadratus

Lumborum

Regev et al, Spine, 2011

Psoas

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Length-Tension Curve

80%

60%

1.0

40%

20%

1.5 2.5 2.0 3.0 3.5 4.0 Sarcomere Length (µm)

Re

lative

Te

nsio

n (

%P

0)

100%

Prone (Neutral)

Flexed

Multifidus Psoas

Regev et al, Spine, 2011

Psoas (PS) & Quad Lumb (QL) Atrophy

• Mixed findings – Atrophy

• Unilateral LBP (3 mos duration): 12.3%1

• Unilateral LBP, most radicular (3 mos duration)2: PS: 7.7-17.1%; QL: 13.9-24.8%

• LBP > 1 year duration3: PS: 13.2%; QL: 13.2%

– No atrophy • Professional dancers4: PS & QL

• Unilateral sciatica5

– Hypertrophy • Chronic nonradicular LBP6 1. Barker, Spine, 2004

2. Ploumis, Br J Radiol, 2011 3. Kamaz, Diag & Interven Radiol, 2007 4. Gildea, JOSPT, 2013 5. Kim, Kor Neurosurg Soc, 2011 6. Arbanas, Eur Spine J, 2013

Psoas Activation with LBP

• Spinal curvature changes

– Psoas major and QL signal amplitude similar to controls.

– Subgrouping: high and low ES EMG activity

• Psoas high when ES low

• Psoas low when ES high

Park, JEK, 2013

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Abdominal Muscle PCSA

Brown et al, Spine, 2011

8

6

0

4

2

5 15 10 20 25 30 Fiber Length (cm)

Physio

log

ic C

ross S

ectional A

rea

(cm

2)


----

---

Incre

asin

g F

orc

e--

----

->

Rectus

Abdominis

Transversus

Abdominis

External

Oblique

Internal

Oblique

Trunk stiffness due to co-contraction from global

muscles

Global Muscle Co-Contraction

Lee et al, J Electromyogr Kin, 2006 Granata et al, Hum Factors, 2004

Load Load

Co-contraction of global muscles increases compression

Importance of recruitment of local muscles

Image complements of Jacek Cholewicki

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Transversus Abdominis

Does not flex the spine or

posteriorly tilt the pelvis.

• Biomechanical effects:

• Resist motion?

• Increase in IAP?

Deep Abdominal Muscle Impairment Associated with LBP

• Onset time delay in CLBP

– Shoulder movements1

• Transversus Abdominis: 61 - 165 ms

• IO: 5 - 54 ms

• EO: 9 – 36 ms

– Hip movements2

• Transversus Abdominis: 119 - 137 ms

• IO: 8 - 38 ms

• EO: 13 – 51 ms

Hodges et al, Spine, 1996 Hodges et al, J Spin Disord, 1998

Bogduk and Twomey. Clinical Anatomy of the Lumbar Spine, 1991

Tension increased segmental stiffness in flexion only1

Fascial tension resisted flexion: 9.5 N (2.2 lbs)1.

Fascial tension decreased extension resistance by ~ 6.6 N.

Forces and moments are a small percentage of those produced by the lumbar extensors ~2-3%2, 3

Transversus Abdominis / IO: Biomechanical Effects Tension through the Thoracolumbar Fascia

1. Barker, Spine, 2006 2. Gatton, J Biomech, 2010 3. Macintosh, Clin Biomech, 1987

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Intra-abdominal Pressure

Created by contraction of abdominal muscles, diaphragm and pelvic floor muscles.

Previously, believed to merely counteract the flexor moment of abdominal muscles.

IAP substantially unloaded spine in all directions of external moments, and exceeded the flexion moment generated by the abdominal muscles1.

Spinal stability was not altered by selective activation by either transversus abdominis or oblique muscles2.

1. Stokes et al, Clin Biomech, 2010 2. Stokes et al, Clin Biomech, 2011

Hollowing vs. Bracing

• Response to sudden loading

– Bracing reduced trunk displacement.

– Hollowing did not reduce trunk displacement.

Vera-Garcia et al, J EMG & Kines, 2007

Physiologic PCSA: Gluteal Muscles

25

0

10

5

5 15 10 20 25 30 Fiber Length (cm)

Physio

log

ic C

ross S

ectional A

rea

(cm

2)


----

---

Incre

asin

g F

orc

e--

----

->

Rectus

Abdominis

Longissimus

Thoracic

Multifidus

15

20

30

Ward, CORR, 2009

Psoas

35

40

Internal

Oblique Transversus

Abdominis

Gluteus

Medius Gluteus

Maximus

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Gluteal Muscle Impairment with LBP

• Duration of Gmax activity diminished during flexion1

• Delayed gluteus maximus activation returning from flexion in LBP developers2

• Delayed gluteus medius activation during stork stand with SIJ pain3

• Hip extensor strength asymmetry in females associated with LBP4 or predicted LBP5

• Gluteus maximus more fatigable with LBP6

1. Leinonen, APM&R, 2000 2. Nelson-Wong, Clin Biomech, 2012 3. Hungerford, Spine, 2003 4. Nadler, Clin J Sports Med, 2000 5. Nadler, Am J Phys Med Rehab, 2001 6. Kankaanpaa, APM&R, 1998

Popovich & Kulig, Med Sci Sports Exerc, 2012

Biomechanical Consequences of Gluteal Muscle Weakness

“simulated facet loading increased during simulated pelvic obliquity”

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Source of Impaired Motor Control?

• Static Load1

– Mechanical stimulus to supraspinous ligament

– Multifidus activated with physiologic loads

– Longissimus not activated until exceeding physiologic loads

• Cyclic Loading2

– Depressed reflex response in feline model

1. Williams et al, Spine, 2000 2. Solomonow et al, Clin Biomech, 2000

Source of Impaired Activation?

• Disc and facet stimulation – Electrical stimulation to right

posterolateral disc

– Electrical activity recorded • Multifidus bilaterally

– Right >left

– Right longissimus only

• Saline injection into facet reduced multifidus activity

Indahl et al, Spine, 1995 Indahl et al, Spine, 1997

Recurrent /

Chronic Low

Back Pain

Cycle

Injury

Reduced Neural

Drive Atrophy

↑ Fatigability ↓ Strength ↓ Rate of Force

Generation

↓ Intervertebral

Stiffness

↓ Pelvic Control

↑ Susceptibility to

Injury

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• Cortical Inhibition? – Porcine Model – Acute Injury1

• MEPs (cortical motor-evoked potentials) recorded in deep and superficial multifidus at L3-5 at side of IV disc lesion.

• MEP amplitudes increased (36%), not decreased on the side of the disc lesion.

• Increased corticomotor excitability suggests a compensatory response to reduced excitability at the spinal cord.

– Reduced cortical excitability in humans with chronic low back pain2

1. Hodges, Eur J Neurosci, 2009 2. Strutton et al, J Spin Disord & Tech, 2005


• Cortical Changes?

– Using TMS mapping, fascicles of

multifidus and erector spinae are

controlled by discrete neuronal regions

within the motor cortex1

– Loss of discrete organization of lumbar

extensors in persons with recurrent LBP2 1. Tsao et al, Clin Neurophys, 2011 2. Tsao et al, Spine, 2011

How do we assess integrated spinal motor control?

1) Postural perturbations

• Anticipated/unanticipated

• Postural control

• Mid-range spinal motion

Macdonald et al., Pain, 2009

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Macdonald et al., Pain, 2009 Jones et al., Exp Brain Res, 2012 Radebold et al., Spine, 2000

Spinal motor control and LBP ACUTE/SUB-ACUTE

LBP

Hodges et al., Exp Brain Res, 2003 Moseley et al., Exp Brain Res, 2004

Control

Attention

Stress

Pain

acceleration again entered simultaneously asacovariate, wasused tocompare themean rectified EMG amplitude for each epoch, for eachmuscle, between conditions. Post hoc testing of EMG onset latencybetween conditions, and the epoch data between conditions, wasundertaken with Duncan’s multiple range test. Significance was setat the 0.05% level of probability.

Results

Stress and pain

Figure 2A–C demonstrates the reported distress and pain,HR and GSR during the control and experimentalconditions. No subjects reported a change in back painduring arm movements. All three measures were greaterduring thestressful task and pain than during theattention-demanding task and control (P<0.01 for both). There wereno differences in these measures between control and theattention-demanding task. Taken together, these measuresindicate that the experimental protocol was effective atselectively targeting attention-demand and stress.

Arm movements

There was no difference in peak shoulder accelerationbetween conditions (P>0.53 for all), which suggests thatthe task was performed in a similar manner during eachcondition. Less than 15% of trials for each subject wereexcluded or rejected because of difficulty in detectingonset. Raw EMG from a representative subject (Fig. 3)and group data (Fig. 4) for the control and experimentalconditions show the general effects of attention-demand,stressful attention-demand and pain on themovement task.The mean ±SD latency of the onset of deltoid and trunkmuscle activation is presented in Table 1. Attention-demand caused an increase in the RT of the task (asevidenced by increased RT of arm movement and deltoidEMG) (P<0.01), but had no effect on activation of thedeep trunk muscles. Stressful attention-demand caused asimilar increase in the RT of the task but also caused adelay in response of the deep trunk muscles (P<0.01)(Fig. 4A). Therefore, relative to the onset of deltoid EMG,the deep trunk muscles were active earlier during atten-tion-demand than during the other conditions (P<0.01).During pain, RT of deltoid and the superficial trunk

Fig. 2 A Means±SD for reported distress (circles) and pain (boxes)during the control and experimental conditions assessed on 11-pointnumerical rating scales (NRS). B Means ±SD for heart rate (HR) asa proportion of mean HR during the control trials, for theexperimental conditions. C Mean ±SD for galvanic skin response

Table 1 Mean ±SD reaction time of deltoid and the trunk muscles (TrA transversus abdominis, Deep MF deep multifidus, OI obliquusinternus, OE obliquus externus, Sup MF superficial multifidus) during single arm movements under control and experimental conditions

Condition Reaction time (ms)

Deltoid TrA Deep MF OI OE Sup MF

Control 180±14 154±15 176±14 168±16 220±37 185±11

Attention-demand 280±16* 164±21 195±35 263±23* 325±46* 281±17*

Stress 286±20* 257±46* 289±41* 263±39* 321±40* 285±20*

Pain 187±16 189±19* 185±50 163±48 212±51 182±42

*Significant difference from control (P<0.01)

67

Mehta et al., J Motor Behav, 2010 Radebold et al., Spine, 2000 Jones et al., J Electromogr Kinesiol 2012

Spinal motor control and LBP

• Task-specific changes in co-contraction

CHRONIC LBP

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• Reduced center of pressure displacement1

• Increased center of mass displacement1

• Reduced preparatory spinal motion2

• Increased resultant spinal motion2

Spinal motor control and LBP CHRONIC LBP

1. Henry et al., Clin Biomech, 2006 2. Mok et al., Spine, 2007


Jacobs et al., Behav Neurosci, 2009

Healthy

LBP

CHRONIC LBP

2) Forward flexion

• Voluntary control

• Through-range spinal motion


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• Lumbopelvic rhythm

• Aberrant motion


ACUTE/SUB-ACUTE LBP

Zedka et al., J Physiol, 1999

Right Erector Spinae Right Erector Spinae

Esola et al., Spine, 1996 McClure et al., Spine, 1997


RECURRENT LBP

LBP

Healthy

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Leinonen et al., Arch Phys Med Rehabil, 2000

Spinal motor control and LBP CHRONIC

LBP

Flexion phase Extension phase

Paraspinals

Gluteus maximus

Biceps femoris

3) Locomotion

• Multi-planar postural control

• Mid-range spinal motion


• Steady-state locomotion

• Perturbed locomotion

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Pelvis rotation (degrees)

Tru

nk

rota

tio

n (

deg

rees

)

-10

-5

0

5

10

-5 0 5 10 Trunk phase

Trunk phase

Pelvic phase

Pelvic phase

In-phase

In-phase Anti-phase

Anti-phase

Steady state locomotion

Trunk phase

Trunk phase

Pelvic phase Pelvic phase

In-phase

In-phase Anti-phase

Anti-phase

Pelvis displacement(degrees)

Tru

nk

dis

pla

cem

ent

(deg

rees

)

Perturbed locomotion

0

20

40

60

80

100

0 20 40 60 80 100

Pelvis angular displacement (degrees)

Tru

nk

angu

lar

dis

pla

cem

ent

(deg

rees

)

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ACUTE/SUB-ACUTE LBP

Lamoth et al., Clin Biomech, 2004

Control condition Pain condition


-20

-15

-10

-5

0

5

10

15

Antiphase Inphase Pelvis phase Trunk phase

Armour Smith & Kulig., unpublished data Seay et al., Spine, 2004

RECURRENT LBP

Ch

ange

in c

oo

rdin

atio

n

pat

tern

(%

of

swin

g p

has

e)

N=20

*p = 0.017, d = 1.19

RLBP CTRL


RECURRENT LBP

-2

-1

0

1

2

3

4

N=20

Ch

ange

in d

ura

tio

n o

f m

ult

ifid

us

acti

vati

on

(%

of

stri

de

cycl

e)

RLBP CTRL

*d = 1.15

Armour Smith & Kulig, unpublished data

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CHRONIC LBP

Healthy LBP

Lamoth et al., Eur Spine J, 2006

Arendt-Nielson et al., Pain, 1996

Healthy LBP

CHRONIC LBP

Vogt et al., Man Ther, 2003

Healthy

LBP

CHRONIC LBP

Thoracic paraspinals

Lumbar paraspinals

Gluteus Maximus

Biceps Femoris

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Van der Hulst et al., J Electromyogr Kinesiol, 2010

Healthy

LBP

CHRONIC LBP

Am

pli

tud

e o

f re

ctu

s a

bd

om

inis

(µ

V)

Biomechanical effects of altered motor control

Assumption

• Some motor control changes are maladaptive and should be modified

Reality? It depends……

• Acute versus chronic situation

• Individual patterns of adaptation

Hodges & Tucker, Pain, 2011


Reeves et al., Clin Biomech, 2007

Increased co-contraction

• Increased spinal stiffness

Granata & Marras, Spine, 2000 Van Dieen et al., Spine, 2003 McGill et al., J Electromyogr Kinesiol, 2003

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Reeves et al., Clin Biomech, 2007

Increased co-contraction

• Increased spinal load1

• Impaired postural control2,3

• Decreased damping4

1. Marras et al., Spine, 2001 2. Mok et al., Spine, 2007 3. Reeves et al., Exp Brain Research, 2006 4. Hodges et al., J Biomech, 2009

Clinical application

Can we assess • muscle morphology? • muscle activation timing? • co-contraction • altered coordination? • altered variability? • response to changing movement

patterns?

Which individuals have these problems?

• Potentially all sub-groups

• Substantial individual variability

• Equivocal findings for relationship between motor control impairments and current classification systems

• Acute/sub-acute/chronic low back pain with movement coordination impairments

Clinical presentation of LBP

Fritz et al., JOSPT, 2007 Kiesel et al., JOSPT, 2007 Silfies et al., Arch Phys Med Rehabil,2009 Zielinski et al., Arch Phys Med Rehabil,2013 Delitto et al., JOSPT, 2012

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Case study

• 24 year old female

• 8 year history

• Bilateral low back pain

• Recurrent episodes

• Chronic discomfort

• Exacerbation due to cycling

“E.P.” Recreational cyclist

Armour Smith, Poppert & Kulig, unpublished data

• Hypermobile

• SLR >90 degrees

• Equivocal prone instability test

• L4 and L5 PAs painful




0

0.1

0.2

0.3

0.4

0

0.1

0.2

0.3

0.4

0.5

Flexion Extension Armour Smith, Poppert & Kulig, unpublished data

Lumbar paraspinals


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-20

0

20

40

60

80

0 10 20 30 40 50

Extension phase

Hip

an

gle

(d

eg

ree

s)

Lumbar spine angle

(degrees)



0 100% Stride cycle

Am

plit

ud

e




Tru

nk

rota

tio

n (

deg

rees

)


-10

-5

0

5

10

-10 -5 0 5 10

-10

-5

0

5

10

-10 -5 0 5 10

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-10

-5

0

5

10

-10 -5 0 5 10


Tru

nk

rota

tio

n (

deg

rees

)

-10

-5

0

5

10

-10 -5 0 5 10

0

10

20

30

40

50

60

70

Co

ord

inat

ion

var

iab

ility

(a

ngu

lar

dev

iati

on

,deg

rees

)

0 100% Stride cycle


Cause or effect?

Transient LBP model

• Pain developers have greater flexor/extensor and gluteal co-contraction1

• On extension from flexion, pain developers have delayed gluteal activation relative to paraspinal activation2

1. Nelson-Wong et al., J Electromyogr Kines, 2010 2. Nelson-Wong et al., Clin Biomech, 2012


motor control impairment


? ?

Cause or effect?




? ?

Prospective study – collegiate athletes

• Delayed muscle offset latencies were predictive of future back injuries

• But is this specific to the trunk or just reflective of generally poor reaction times?

Cholewicki et al., Spine, 2005

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Pain-spasm-pain model

PAIN

spasm ischemia

Why is motor control different in individuals with LBP?

Travell et al., JAMA, 1942 Van Dieen et al., J Electromyogr and Kines, 2003 Hodges & Tucker, Pain, 2011

Pain - adaptation model

Lund et al., Can J Physiol Pharm, 1991 Van Dieen et al., J Electromyogr and Kines, 2003 Hodges & Tucker, Pain, 2011

agonist

PAIN

antagonist


• Adaptation specific to muscle, task, and individual

• Complex due to complexity and redundancy of trunk muscle system


– Musculoskeletal system

– Central nervous system

– Sensory/perceptual processes

– Cognitive processes

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Sensory/perceptual and cognitive processes

CHRONIC LBP

Effects of:

• Anticipation of back pain1

• Fear avoidance2

• Diffuse impairments in body perception3

• Diffuse impairments in sensory processing3

• Altered cognitive control of motor activities4

1. Moseley et al., Brain, 2004 2. Al-Obaidi et al., Int J Rehabil Res, 2003 3. Wand et al., Man Ther, 2011 4. Lamoth et al., J NeuroEngineering Rehabil, 2008

• Delay in APA onset and reduction in variability of APA onset prolonged in some healthy subjects1

• Associated with pain beliefs1

• Altered cognitive control of locomotion in persons with CLBP2

CHRONIC LBP

1. Moseley & Hodges, Behav Neurosci, 2006 2. Lamoth et al., J NeuroEngineering Rehabil, 2008

Sensory/perceptual and cognitive processes

ACUTE/SUB-ACUTE LBP

How do we modify trunk motor control?

• Manual techniques

• Exercise interventions

• Motor (re)learning

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Extensor Activation Post Manipulation (sEMG)

• EMG amplitude decreased1

• EMG amplitude diminished at painful segment only after manipulation2

• Increase in sEMG amplitude during MVIC after manipulation3

1. DeVocht, JMPT, 2005 2. Lehman, JMPT, 2001 3. Keller, JMPT, 2000

Multifidus Post Manipulation Activation - US


• On average, total group (N=81) had greater activation at L4-5 at 3-4 days.

• MF increase in thickness explained only 7% of variance in ODI score

• Responders (≥30% ODI reduction) experienced significantly more activation at 3-4 days, but not immediately or 1 week later.

Koppenhaver, J Orthop Sports Phys Ther, 2011

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• Variables together resulted in an adjusted R2 of 0.27 - change in LM thickness 1 week post-manipulation.

1. Acute LBP

2. Moderately good prognosis without focal and irritable symptoms

3. Signs of spinal instability

Koppenhaver et al, JEK, 2012

Abdominal Activation Post Manipulation

• Feedforward activation improved post-manipulation in healthy individuals with delay1

• Case series meeting manipulation CPR – 6 of 9 patients increased TrA muscle thickness during ADIM post-manipulation2

• Rapid shoulder flexion – persons with LBP (not control group) exhibited higher amplitudes in both IO and EO (fine-wire EMG)3

– Persons with LBP – increased IO and EO activation post-manipulation. TrA and RA: no change.

1. Marshall, JMPT, 2006 2. Raney, JOSPT, 2007 3. Ferreira, Man Ther, 2007

Abdominal Activation Post Manipulation

• N=81, met and did not meet manipulation CPR1 – TrA thickness change decreased immediately post

SMT during ADIM.

– IO thickness change decreased immediately post SMT during ASLR.

– No change 1 week post SMT.

– No change in those who improved from manipulation.

• Case series – met stabilization CPR: “No significant differences in resting, contracted, or percent thickness change in the TrA or IO were found over the 3 time periods.”2

1. Koppenhaver, JOSPT, 2011 2. Konitzer, JOSPT, 2011

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• Does isolated muscle training affect timing of postural activation in short and long term?

• Isolated muscle training may help to redistribute muscle activation

• Isolated muscle training may affect motor cortical spatial representation

Is motor control intervention effective?

Tsao et al., J Electromyogr Kinesiol, 2008 Vasseljen et al., Spine, 2012 Tsao et al., J Pain, 2010 Tsao et al., Eur J Pain, 2010

• Motor skill training (versus general exercise) can alter corticospinal excitability and cortical representation

• Strength training increases excitability, but skill training alters representation


Boudreau et al., Man Ther, 2010 Adkins et al., J Appl Physiol, 2006 Fisher et al., JOSPT, 2013

Intervention

• Multi-modal intervention may improve timing of gluteus maximus activation1

• Trunk/hip strengthening intervention reduced pain but had variable outcome on co-contraction during prolonged standing2

• Task-specific training may alter coordination and movement patterns3

• Movement re-education may reduce symptoms4

1. Leinonen et al., Arch Phys Med Rehabil, 2000 2. Nelson Wong et al., J Electromyogr Kinesiol, 2010 3. Hoffman et al., Man Ther, 2012 4. Van Dillen et al., Man Ther, 2009

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Multifidus Atrophy Localized to Painful Region - Postural Cuing

L5

L5

T12 T12

Healthy: matched for age, size and activity

Low Back Pain

• Short Lordosis

– Verbal Cue: “Push your tailbone up over your head”

• Unilateral activation

– Short lordosis cue

– “Swing your tailbone to the right”

• Palpatory feedback

Training with Postural Cuing

Multifidus Longissimus Thoracic

L5

T12

Postural Cuing Activation Lower Lumbar

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Postural Cuing Activation Kneeling Side Bridge

Exercises

1. CONTRALATERAL ARM/LEG EXT

2. SIDE PLANK ON KNEES

3. PRONE LEG LIFT

4. PRONE TRUNK EXTENSION

6. VARC 15˚ 5. VARC 45˚


• 12 week progressive intervention

• Motor learning and strengthening

• Trunk and lower extremity musculature


Kulig et al., Phys Ther, 2009 Flanagan, Kulig & PTCLINRESNET, JOSPT, 2010

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• Multifidus

• Transversus Abdominis

• Quadruped progression

• Abdominal progression

• Squat/lunge progression

• Modified paraspinal progression

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No pain

Worst pain imaginable

Sitting 5 minutes

Standing 5 minutes


0

0.1

0.2

0.3

0.4

0

0.2

0.4

0.6


-20

0

20

40

60

80

0 10 20 30 40 50

Flexion Extension

Post-intervention Pre-intervention

Hip

an

gle

(d

eg

ree

s)


Lumbar paraspinals


Lumbar angle (degrees)


Pre-intervention

Post-intervention

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

On

se

t o

f th

ora

cic

mu

scle

activity r

ela

tive

to

glu

t m

ax

(s)


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Co

ord

inat

ion

var

iab

ility

(a

ngu

lar

dev

iati

on

, deg

rees

)

0

20

40

60

80

100% Stride cycle

0%

Du

ratio

n o

f th

ora

cic

mu

scle

activity

(% o

f str

ide

cycle

)

0

5

10

15

20

25

30

Pre-intervention

Post-intervention


Intervention

Boudreau et al., Man Ther, 2010

Recognize individual adaptations to pain

Maximize neuroplasticity

• Motor skill training

• Cognitive effort

• Quality not quantity of repetition

• Modulate complexity of task and environment

Framework for intervention

MUSCLE PERFORMANCE

load

reps duration

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CONTROL

cognition

context complexity

Framework for intervention

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Selected References • Beneck GJ, Baker LL, Kulig K. Spectral analysis of EMG using intramuscular electrodes reveals non-linear fatigability characteristics in persons with

chronic low back pain. J Electromyogr Kinesiol. 2013;23:70-7.

• Beneck GJ, Kulig K. Multifidus atrophy is localized and bilateral in active persons with chronic unilateral low back pain. Arch Phys Med Rehabil.

2012;93:300-6.

• Boudreau, SA., Farina D, & Falla D. The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. Man Ther., 2010; 15: 410–414.

• Brown SH, Ward SR, Cook MS, Lieber RL. Architectural analysis of human abdominal wall muscles: implications for mechanical function. Spine (Phila

Pa 1976). 2011;36:355-62.

• Delitto A, George SZ, Van Dillen L, et al. Low back pain. J Orthop Sports Phys Ther. 2012; 42: A1-A57.

• DeVocht JW, Pickar JG, Wilder DG. Spinal manipulation alters electromyographic activity of paraspinal muscles: a descriptive study. J Manipulative

Physiol Ther. 2005;28:465-471.

• Esola MA, McClure PW. Fitzgerald GK, & Siegler S. Analysis of lumbar spine and hip motion during forward bending in subjects with and without a history of low back pain. Spine.1996;21: 71–78.

• Fisher BE, Lee YY, Pitsch EA, et al. Method for Assessing Brain Changes Associated With Gluteus Maximus Activation. J Orthop Sports Phys Ther.2013: 43: 214-221.

• Flanagan SP, Kulig K, & PTClinResNet. Time courses of adaptation in lumbar extensor performance of patients with a single-level microdiscectomy during a physical therapy exercise program. J Orthop Sports Phys Ther.2010; 40: 336–344.

• Ferreira ML, Ferreira PH, Hodges PW. Changes in postural activity of the trunk muscles following spinal manipulative therapy. Man Ther.

2007;12:240-8.

• Gatton ML, Pearcy MJ, Pettet GJ, Evans JH. A three-dimensional mathematical model of the thoracolumbar fascia and an estimate of its biomechanical effect. J Biomech. 2010;43:2792-7.

• Henry S, Hitt J, Jones S, & Bunn J. Decreased limits of stability in response to postural perturbations in subjects with low back pain. Clin Biomech,

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• Hodges PW, Galea MP, Holm S, Holm AK. Corticomotor excitability of back muscles is affected by intervertebral disc lesion in pigs. Eur J Neurosci. 2009;29:1490-500.

• Hodges PW, & Tucker K. Moving differently in pain: A new theory to explain the adaptation to pain. Pain. 2011; 152: S90–S98.

• Hodges P, van den Hoorn W, Dawson A, & Cholewicki J.. Changes in the mechanical properties of the trunk in low back pain may be associated with recurrence. J Biomech. 2009; 42: 61–66.

• Hoffman SL, Johnson MB, Zou D, Harris-Hayes M, & Van Dillen LR. Effect of classification-specific treatment on lumbopelvic motion during hip rotation in people with low back pain. Man Ther. 2011;16: 344–350.

• Konitzer LN, Gill NW, Koppenhaver SL. Investigation of abdominal muscle thickness changes after spinal manipulation in patients who meet a clinical prediction rule for lumbar stabilization. J Orthop Sports Phys Ther. 2011;41:666-74.

• Koppenhaver SL, Fritz JM, Hebert JJ, et al. Association between changes in abdominal and lumbar multifidus muscle thickness and clinical improvement after spinal manipulation. J Orthop Sports Phys Ther. 2011;41:389-99.

• Kulig K, Beneck GJ, Selkowitz DM, et al. An intensive progressive exercise program reduces disability and improves functional performance in patients after single-level lumbar microsdiskectomy. Phys Ther. 2009: 89: 1145-1157.

• Lamoth C, Daffertshofer A, Meijer O, Beek P. How do persons with chronic low back pain speed up and slow down? Gait and Posture. 2006; 23: 230-239.

• MacDonald D, Moseley GL, Hodges PW. People with recurrent low back pain respond differently to trunk loading despite remission from symptoms. Spine (Phila Pa 1976). 2010;35:818-24.

• Marras WS, Davis KG, Ferguson SA, Lucas BR, & Gupta P. Spine loading characteristics of patients with low back pain compared with asymptomatic individuals. Spine. 2001; 26, 2566–2574.

• Marshall P, Murphy B. The effect of sacroiliac joint manipulation on feed-forward activation times of the deep abdominal musculature. J Manip Phys Ther. 2006;29:196-202.

• Mok NW, Brauer SG, & Hodges PW. Failure to use movement in postural strategies leads to increased spinal displacement in low back pain. Spine. 2007; 32: E537–43.

• Nelson-Wong E, & Callaghan JP. Is muscle co-activation a predisposing factor for low back pain development during standing? A multifactorial approach for early identification of at-risk individuals. J Electromyogr Kinesiol. 2010; 20: 256–263.

• Popovich JM Jr, Kulig K. Lumbopelvic landing kinematics and EMG in women with contrasting hip strength. Med Sci Sports Exerc. 2012;44:146-53.

• Raney NH, Teyhen DS, Childs JD. Observed changes in lateral abdominal muscle thickness after spinal manipulation: a case series using rehabilitative ultrasound imaging. J Orthop Sports Phys Ther. 2007;37:472-479.

• Regev GJ, Kim CW, Tomiya A, et al. Psoas muscle architectural design, in vivo sarcomere length range, and passive tensile properties support its role as a lumbar spine stabilizer. Spine (Phila Pa 1976). 2011;36:E1666-74.

• Silfies SP, Mehta R, Smith SS, & Karduna AR. Differences in Feedforward Trunk Muscle Activity in Subgroups of Patients With Mechanical Low Back Pain. Arch Phys Med Rehabil. 2009;90: 1159–1169.

• Stokes IA, Gardner-Morse MG, Henry SM. Intra-abdominal pressure and abdominal wall muscular function: Spinal unloading mechanism. Clin Biomech. 2010;25:859-66.

• Tsao H, Danneels LA, Hodges PW. Smudging the motor brain in young adults with recurrent low back pain. Spine. 2011; 36: 1721-1727.

• Tsao H, Danneels L, Hodges PW. Individual fascicles of the paraspinal muscles are activated by discrete cortical networks in humans. Clin Neurophysiol. 2011;122:1580-7.

• Tsao H, Druitt TR, Schollum TM, Hodges PW. Motor training of the lumbar paraspinal muscles induces immediate changes in motor coordination in patients with recurrent low back pain. J Pain. 2010;11:1120-8.

• van der Hulst M, Vollenbroek-Hutten MM, Rietman JS, & Hermens HJ. Lumbar and abdominal muscle activity during walking in subjects with chronic low back pain: Support of the “guarding” hypothesis? J Electromyogr Kinesiol. 2010; 20: 31–38.

• van Dieën JH, Selen LPJ, & Cholewicki J. Trunk muscle activation in low-back pain patients, an analysis of the literature. J Electromyogr Kinesiol. 2003; 13: 333–351.

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