Muscle Activation Changes After Exercise Rehabilitation for Chronic Low Back Pain

doi:10.1016/j.apmr.2007.11.051

Archives of Physical Medicine and Rehabilitation

Volume 89, Issue 7, July 2008, Pages 1305-1313

https://doi.org/10.1016/j.apmr.2007.11.051 Get rights and content

Abstract

Marshall PW, Murphy BA. Muscle activation changes after exercise rehabilitation for chronic low back pain.

Objective

To investigate the changes in 2 electromyographic measures, flexion relaxation (FR) response and feed-forward activation of the deep abdominals, associated with low back pain (LBP) after different rehabilitation interventions.

Design

A 2×2 factorial design with subjects' self-selecting treatment with randomization after 4 weeks to either the specific exercise group or exercise advice group for a further 12-week period.

Setting

General community practitioners and university training center.

Participants

Subjects with chronic nonspecific LBP were recruited for this study. A total of 112 people were initially screened, and 60 were recruited for the study, with 50 being available for long-term follow-up.

Intervention

Four weeks of treatment (manipulative or nonmanipulation) and 12 weeks of subsequent exercise (supervised Swiss ball training or exercise advice).

Main Outcome Measures

The Oswestry Disability Index, FR response measured at T12-L1 and L4-5, and feed-forward activation of the deep abdominal muscles.

Results

More rapid improvements in disability were identified for subjects who received the supervised exercise program. The FR response at L4-5 also increased more for those who received directly supervised exercise. Long-term follow-up showed that there was still a between-group difference in the FR response, despite no difference in self-rated disability. Long-term changes were observed for the feed-forward activation of the deep abdominals; however, no exercise or treatment effects were identified.

Conclusions

Supervised exercise rehabilitation leads to more rapid improvements in self-rated disability, which were associated with greater improvement in the low back FR response.

Section snippets

Participants

Sixty men and women with chronic nonspecific LBP of at least 3 months in duration volunteered to participate in this study from a total of 112 people who were screened for participation (fig 1). This study was approved by our local ethics committee, and all subjects provided informed written consent before participation. Exclusion criteria included the presence of severe postural abnormality or neuromuscular disorder; previous diagnosis of pathology (confirmed by magnetic resonance imaging or

Results

The results from table 1 present the demographic information from the subjects separated by group.

Summary of the Main Results

The results of this study do not support the hypothesis that spinal manipulation and exercise would lead to a greater change in the neuromuscular measures used in this study compared with the alternative treatment groups. However, the study results did provide support for the efficacy of supervised exercise in yielding a more rapid improvement in functional disability and the FR response.

Changes in FR Response

There is some research that has found improvements in the FR response after exercise, specifically manifest

Conclusions

Supervised exercise was a more rapid means of eliciting neuromuscular improvement, manifest by an increased FR response. The unsupervised exercise program also showed chronic neuromuscular improvement. No treatment effects were identified for either neuromuscular improvements or disability, although there is a possibility of type II error because sample-size calculations were based on changes in disability. This study has provided data that can be used for future sample size calculations in

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Cited by (70)

Sensitivity and specificity of the flexion and extension relaxation ratios to identify altered paraspinal muscles’ flexion relaxation phenomenon in nonspecific chronic low back pain patients
2023, Journal of Electromyography and Kinesiology
Among the main methods used to identify an altered flexion relaxation phenomenon (FRP) in nonspecific chronic low back pain (NSCLBP), it has been previously demonstrated that flexion relaxation ratio (FRR) and extension relaxation ratio (ERR) are more objective than the visual reference method.
To determine the sensitivity and specificity of the different methods used to calculate the ratios in terms of their ability to identify an altered FRP in NSCLBP.
Forty-four NSCLBP patients performed a standing maximal trunk flexion task. Surface electromyography (sEMG) was recorded along the erector spinae longissimus (ESL) and multifidus (MF) muscles. Altered FRP based on sEMG was visually identified by three experts (current standard). Six FRR methods and five ERR methods were used both for the ESL and MF muscles. ROC curves (with areas under the curve (AUC) and sensitivity/specificity) were generated for each ratio.
All methods used to calculate these ratios had an AUC higher than 0.9, excellent sensitivity (>90 %), and good specificity (80–100 %) for both ESL and MF muscles.
Both FRP ratios (FRR and ERR) for MF and ESL muscles, appear to be an objective, sensitive and specific method for identifying altered FRP in NSCLBP patients.
The effect of exercise engagement on low back disability at 12-months is mediated by pain and catastrophizing in a community sample of people with chronic low back pain
2022, Behaviour Research and Therapy
Despite being a first-line treatment recommendation, there is uncertainly for how exercise helps people with chronic low back pain. We designed this study to examine how exercise might help people with chronic low back pain by following a large community sample for 1-year. Qualitative questionnaires and self-report measures were collected every 3-months for 1-year in 400 people with chronic low back pain. People were not provided any specific treatment advice as part of this study but were allowed to engage with any normal physical activity, treatment, or medication as part of their normal life. Exercise engagement was defined from inspection of participant qualitative responses, according to minimum acceptable levels of exercise that elicit symptom reduction. Multiple mediation analysis was performed to examine the effect of exercise engagement on disability through the proposed mediators (pain, fear, catastrophizing, depression, anxiety, self-efficacy). The significant effect of exercise engagement on reductions in disability at 6- and 12-months was explained through pain and catastrophizing. People with chronic low back pain who reported worsening of symptoms over the year had similar reporting of exercise throughout the 12-months to people who had improvements in disability. Exercise can reduce disability through the effect on pain and catastrophizing, but how this effect occurs (i.e., an active or passive component of exercise) is unclear.
Anticipatory and compensatory postural adjustments in people with low back pain: a systematic review and meta-analysis
2018, Spine Journal
Despite altered anticipatory (APAs) and compensatory postural adjustments (CPAs) being hypothesized to contribute to the onset and persistence of low back pain (LBP), results from studies comparing people with and without LBP are conflicting.
This systematic review aimed to determine whether APAs or CPAs are altered in the presence of acute and chronic LBP.
A systematic review of studies was carried out.
No patient sample was required.
Between group standardized mean differences and 95% confidence intervals for APAs ad CPAs
A comprehensive search was conducted for articles comparing people with LBP (acute or chronic) to healthy controls for the onset or amplitude of muscle activity, center of pressure (COP), or kinematic responses to expected or unexpected perturbations. Two independent reviewers extracted data and assessed the methodological quality of relevant studies. Differences between people with and without LBP were calculated as standardized mean differences, and included in a meta-analysis if outcomes were homogeneous. Otherwise, a narrative synthesis was conducted.
Twenty-seven studies were included, of which the majority examined muscle onsets in response to expected and unexpected perturbations. Only two studies compared people with and without acute LBP, and results for these studies were conflicting. The results show delayed muscle onsets in response to expected and unexpected perturbations for people with chronic LBP when compared with healthy controls. No conclusive evidence for differences between people with and without chronic LBP for COP or kinematic responses.
There is currently no convincing evidence of differences between people with and without acute LBP for APAs or CPAs. Conversely, delayed muscle onsets in people with chronic LBP suggest APAs and CPAs are altered in this population. However, the functional relevance of these delayed muscle onsets (eg, COP and kinematics) is unknown.
Trunk postural adjustments: Medium-term reliability and correlation with changes of clinical outcomes following an 8-week lumbar stabilization exercise program
2018, Journal of Electromyography and Kinesiology
Low back pain (LBP) has been previously associated with delayed anticipatory postural adjustments (APAs) determined by trunk muscle activation. Lumbar stabilization exercise programs (LSEP) for patients with LBP may restore the trunk neuromuscular control of the lumbar spine, and normalize APAs. This exploratory study aimed at testing the reliability of EMG and kinematics-based postural adjustment measures over an 8-week interval, assessing their sensitivity to LBP status and treatment and examining their relationship with clinical outcomes.
Muscle activation of 10 trunk muscles, using surface electromyography (EMG), and lumbar angular kinematics were recorded during a rapid arm-raising/lowering task. Patients with LBP were tested before and after an 8-week LSEP. Healthy controls receiving no treatment were assessed over the same interval to determine the reliability of the measures and act as a control group at baseline. Muscle activation onsets and reactive range of motion, range of velocities and accelerations were assessed for between group differences at baseline and pre- to post-treatment effects within patients with LBP using t-tests. Correlations between these dependent variables and the change of clinical outcomes (pain, disability) over treatment were also explored.
Kinematic-based measures showed comparable reliability to EMG-based measures. Between-group differences were found in lumbar lateral flexion ROM at baseline (patients < controls). In the patients with LBP, lateral flexion velocity and acceleration significantly increased following the LSEP. Correlational analyses revealed that lumbar angular kinematics were more sensitive to changes in pain intensity following the LSEP compared to EMG measures. These findings are interpreted in from the perspective of guarding behaviors and lumbar stability hypotheses.
Future clinical trials are needed to target patients with and without delayed APAs at baseline and to explore the sensitivity of different outcome measures related to APAs. Different tasks more challenging to postural stability may need to be explored to more effectively reveal APA dysfunction.
Improved compensatory postural adjustments of the deep abdominals following exercise in people with chronic low back pain
2017, Journal of Electromyography and Kinesiology
The purpose of this study was to determine if 8 weeks of exercise affects motor control in people with chronic low back pain (CLBP), measured by anticipatory (APAs) and compensatory postural adjustments (CPAs). APAs and CPAs were measured prior to and following 8 weeks in two groups of people with CLBP: an exercise group (n = 12) who attended three exercise sessions per week for 8 weeks; and a non-exercise control group (n = 12) who were advised to continue their usual activities for the duration of the study. APAs and CPAs were recorded during unilateral arm flexion, bilaterally from rectus abdominis (RA), transverse abdominis/internal oblique (TA/IO), and erector spinae (ES) via surface electromyography. Analysis of muscle onsets and APA amplitudes suggests APAs did not change for either group. Ipsi-lateral TA/IO CPAs increased for the exercise group and ipsi-lateral TA/IO CPAs decreased for the control group. Only exercise promoted a pattern of TA/IO activity during CPAs similar to healthy individuals, suggesting improved control of rotational torques. These results show motor control improvement following exercise in people with CLBP, highlighted by improved side specific control of TA/IO.
Effect of movement control and stabilization exercises in people with extension related non -specific low back pain- a pilot study
2017, Journal of Bodywork and Movement Therapies
Exercise is considered an effective treatment strategy for non-specific chronic low back pain (NSCLBP).background
In spite of the wide use of exercise protocols, it is not clear what type of exercise is more effective in decreasing pain, disability and normalizing muscle activation patterns in people with chronic low back pain.
To assess the effects of two exercise protocols (stabilization vs movement control) on pain and disability scores and the flexion relaxation ratio (FRR) of lumbar multifidus (LM) and iliocostalis lumbarum pars thoracic (ICLT) in people with extension related non-specific chronic low back pain.
Pilot randomized control trial.
32 subjects with active extension pattern chronic low back pain (stabilization group = 16, movement control group = 16) participated in this study. Treatment groups received 4 weeks of exercise therapy. Outcomes were based on pain score (Numeric rating Scale-NRS), disability (Oswestry Disability Index- ODI) and FRR of the LM and ICLT.
Four people dropped out of the study in each group for reasons unrelated to the protocols of the study. Pain and disability reduced in both groups, with no significant difference between the groups. The FRR of LM did not change in either treatment group after treatment. However, the FRR of ICLT was significantly increased after treatment in the movement control group.
Both movement control and stabilization exercises reduced pain and disability in the short-term among people with extension pattern NSCLBP, with no difference in effectiveness between the groups. However, movement control exercises were more effective in normalizing back muscle activation patterns than stabilization exercises.

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Original articleMuscle Activation Changes After Exercise Rehabilitation for Chronic Low Back Pain

Abstract

Objective

Design

Setting

Participants

Intervention

Main Outcome Measures

Results

Conclusions

Section snippets

Participants

Results

Summary of the Main Results

Changes in FR Response

Conclusions

Aust J Physiol

Man Ther

J Electromyogr Kinesiol

J Biomech

Clin Biomech (Bristol, Avon)

J Manipulative Physiol Ther

J Manipulative Physiol Ther

J Electromyogr Kinesiol

J Electromyogr Kinesiol

Pain

Arch Phys Med Rehabil

J Electromyogr Kinesiol

Man Ther

Neurosci Lett

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Quantifying the lumbar flexion-relaxation phenomenon: theory, normative data, and clinical applications

Spine

Therapeutic exercise for spinal segmental stabilisation in low back pain

Muscle action potentials used in the study of dynamic anatomy

Br J Phys Med

The function of the erector spinae muscles in certain movements and postures in man

J Physiol

Original article
Muscle Activation Changes After Exercise Rehabilitation for Chronic Low Back Pain