Active Care: An Evidence-Informed Approach to Self-Care for Patients with Spine Pain
Craig Liebenson
James E. Eubanks
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
Understand the current state of knowledge for the diagnosis and classification of patients with low back disorders.
Understand the relationship between functional disturbances and spinal disorders.
Understand the complexity of individual and environmental/social aspects influencing function.
Understand the relationship between psychosocial factors, such as fear-avoidance behavior, and deconditioning syndrome.
Understand the distinction between impairments, such as losses of strength or mobility, and disability, such as walking or sitting intolerances.
Understand the evidence for the effectiveness of active care in patients with spinal disorders.
“To hope under the most extreme circumstances is an act of defiance that permits a person to live one’s life on one’s own terms. It is part of the human spirit to endure and give triumph a chance to happen.
–JEROME GROOPMAN, MD
Introduction
Activity has been shown to be effective for preventing or treating many of the most common chronic ailments in our society today.1,2 In particular, active care or patient reactivation plays a decisive role in the modern management of disorders of the cardiovascular and locomotor systems.3,4,5,6,7,8,9,10,11 From simple, reactivation advice to more comprehensive, multidisciplinary rehabilitation, the goal is to restore function. The functional goal is an essential hinge for guiding clinicians in the decision-making process. Biomechanical, neurophysiologic, psychosocial, and biochemical rationales exist for the benefits of active care. However, the most important justification for making reactivation a primary focus of care is that patients in pain tend to accept the adage “let pain be your guide,” resulting in deconditioning from their pain.
Persistent pain reinforces negative attitudes about the relationship of activity and pain as the patient takes on the “sick” role.12 The sick role is further reinforced when clinicians employ corresponding attitudes and beliefs.13 Diagnostic tests that focus on pathoanatomy are frequently ordered to find the “cause” of the pain. Unfortunately, these tests have high false-positive rates for incidental structural findings, such as degenerative changes or herniated discs, and thus reinforce the patient’s self-image as having a “bad” back or needing to “learn to live with it.”14,15,16,17,18,19,20,21,22 The result is further activity avoidance and deconditioning. Excessive immobilization interferes with the healing, coping, and recovery process. Thus, health care professionals are being urged by each successive international guideline on spinal disorders to first perform a diagnostic triage to rule out “red flags” of rare but serious disease, and then to reassure patients of the benign nature of their back pain and the safety and value of gradually resuming activities.4,23,24,25,26,27,28 As stated by Tousignant-Laflamme et al, “It’s time to pull it all together.”29
The evidence in favor of reactivation for spine patients is strong. Reactivation advice to resume near-normal activities is both safe and effective for acute low back pain (LBP) patients.26 Similarly, early activation has been found to be effective for neck pain after a whiplash injury.30,31,32 Engaging in early reactivation has been associated with larger improvements in functional outcomes and pain ratings, as well as reduction in opioid use.33,34,35,36,37,38 Deconditioning normally accompanies acute LBP, and its prevention has been shown to reduce recurrence rates.39,40,41 Active therapies involving such diverse exercise methods as cognitive-behavioral, stabilization, and strengthening have demonstrated their effectiveness for subacute and chronic LBP.4,5,40,42,43,44,45,46,47,48,49 Especially in the case of chronic pain, reactivation may largely depend on resilience—a characteristic developed through positive affect and psychological flexibility.50 Therefore, at each phase of the acute to chronic pain continuum, patient reactivation has been shown to play a fundamental role.
The Functional Paradigm in Diagnosis and Therapy
Practice-Based Problem
LBP is a subjective symptom that correlates poorly with objective findings. According to Berg et al, combined degenerative magnetic resonance imaging (MRI) findings were not related to the degree of disability or the intensity of LBP.51 Less than 15% of LBP patients can be given a precise pathoanatomic diagnosis. These patients are labeled with general terms such as sprain/strain, “nonspecific,” or idiopathic LBP. Fortunately, most low back conditions have a favorable natural history. However, patients who don’t recover rapidly with “tincture of time” can become frustrated. The physician shares in this frustration and may order diagnostic tests that have low predictive value and thus are unlikely to make a difference in patient care. In fact, the reservoir of coincidental structural pathology (false-positive results) in patients is so high that performing advanced imaging injudiciously has the unwanted side effect of increasing anxiety and propagating an undesirable, interventionist cascade in pursuit of the cause of the pain.52,53,54
The problem of back pain then is not what to do for the majority who have a satisfactory outcome, but rather what to do for the disproportionately costly minority of patients who do not. Because the goal of care is to restore function, are we able to identify the impairments and cognitive-behavioral factors that limit performance, so that treatment decisions can be guided by a valid, logical reasoning process?
The Diagnostic Dilemma in Back Pain
The Problem LBP is a common problem affecting both genders and most ages, for which about one in four adults seeks care in a 6-month period.55 Optimal clinical management depends on accurate diagnosis. Unfortunately, only a minority of back pain patients can be given a clear diagnosis of their pain generator or relevant pathoanatomy.23 The conundrum of the LBP problem is that most patients do well despite this diagnostic failure, yet most costs arise from the few who become chronically disabled.56
Current “state-of-the-art” guidelines suggest performing a diagnostic triage to classify patients with low back problems into three distinct groups. (Please see Chapters 2 and 6) First, LBP caused by “red flags” of serious disease, for example, tumor, infection, fracture, or serious medical disease (<2%); second, LBP caused by nerve root compression (<10%); and third, LBP caused by “nonspecific” mechanical factors (85%-90%).23,25,27 This “state-of-the-art” will hopefully evolve because the most crucial of all “stake holders”—the patients—are dissatisfied with the diagnosis “nonspecific” back pain.24,57,58,59
Emerging evidence shows a strong association between psychosocial factors and chronic LBP. These psychosocial illness traits (i.e., fear-avoidance behavior, anxiety) have been termed “yellow flags” to distinguish their relative importance from “red flags” of potentially serious disease processes. Individuals with a preponderance of “yellow flags” are at heightened risk for chronic symptoms and disability60,61,62,63,64,65 and thus require a carefully mapped out management strategy. The strength of the association between “yellow flags” and spinal pain syndromes is reinforced by the prospective studies involving asymptomatic individuals, which have shown that they predicted both future acute episodes66 and who is likely to have chronic problems.67 Clinicians exposed to a brief psychologically informed training session demonstrated improved attitudes toward the treatment of those with chronic pain where psychosocial factors play a prominent role.68 Importantly, there is evidence that psychosocial illness behavior can be improved merely by active rehabilitation alone.69
A burning question in the low back field remains how to identify the patients who will respond best to individual interventions. Although general guidelines adhering to a biopsychosocial model have emerged that point out past errors and suggest a new path, there are still many unanswered questions.70 For instance, which patients respond best to manipulation, reactivation advice, exercise, medication, cognitive-behavioral approaches, or to various combinations of these?
The Challenge of the Label “Nonspecific” LBP Contemporary research on the effectiveness of different treatments has assumed that “nonspecific” back pain is a homogenous group.71 Leboeuf et al has urged researchers to appreciate that patients lacking either “red flags” or nerve root signs or symptoms are most likely a heterogeneous group (Figs. 4.1 and 4.2).72,73 She points out that research that assumes this large patient population is homogenous and would fail to show statistical clinical effectiveness for specific interventions beneficial for a certain smaller subgroup. The result is that a promising treatment would be erroneously assumed to be ineffective. The Cochrane Back Review Group refers to identification of subgroups as “the Holy Grail”.74
 Figure 4.1 Nonspecific low back pain (LBP) may consist of subtypes of LBP with different causes. From Laboeuf-Yde C, Lauritsen JM, Lauritzen T. Why has the search for causes of low back pain largely been nonconclusive? Spine. 1997;22:878. |
 Figure 4.2 A positive association between a suspected risk factor and a nonspecific low back pain (LBP) will become apparent only if the study sample contains a sufficient number of people with the “right” subtype of LBP that matches the risk factor undergoing study. From Laboeuf-Yde C, Lauritsen JM, Lauritzen T. Why has the search for causes of low back pain largely been nonconclusive? Spine. 1997;22:878. |
Work at the University of Pittsburgh has suggested that identifying subgroups within the nonspecific label is something we should strive for (Table 4.1).75,76,77 Data suggest that treatment that is matched to the appropriate subclassification is superior to unmatched treatments.75 A randomized controlled trial (RCT) also supported this line of thinking.78 Work from the University of Southern Denmark revealed that although latent class-derived subgroups provided additional
prognostic information, the improvements were not substantial enough to warrant further development into a prognostic tool.79
prognostic information, the improvements were not substantial enough to warrant further development into a prognostic tool.79
Table 4.1 Treatment-Based Classification System | ||
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Alrwaily et al posit that treatment prioritization should aim to consecutively address neural sensitivity, joint(s) and soft-tissue mobility, motor control, and endurance. This prioritization enables rehabilitation providers to better plan the intervention according to each patient’s needs. The authors emphasize that treatment for patients with LBP is not a static process, but rather a fluid process that changes as the clinical status of the patient changes. This movement control approach currently depends on clinical experience and indirect evidence; further research is needed to support its clinical utility.80
The McKenzie method by itself has been shown to be a promising classification system.77,81,82,83 The classic McKenzie approach of using repeated movements and end-range loading strategies is to identify (a) if the centralization phenomenon was present and (b) the patient’s movement bias (i.e., directional preference) is a standard of many evidence-based spine practitioners. Interexaminer reliability of the assessment has not been shown to be robust.84
Others such as researchers at Washington University, applying the methods of Shirley Sahrmann, P. T., have attempted to validate a subclassification scheme on the basis of identifying the posture or movement that is consistently associated with increasing the patient’s LBP.85,86,87,88,89 Similarly, in Toronto, a group associated with the Canadian Back Institute showed the reliability of a pain pattern system using key elements from the history and examination.90 However, both these approaches are not validated at this time. Table 4.2 highlights the steps required to evaluate diagnostic/classification procedures. The emerging evidence shows great promise for the ability to determine mutually exclusive categories of mechanical LBP that can guide the treatment decision-making process.
Table 4.2 Evaluation of Diagnostic Procedures | ||
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Professor McGill argues that we should practically attempt to make a precise diagnosis of the pain generator in all patients.59 His argument is that a thorough individualized assessment should always be carried out to identify what postures, movements, and loads are pain triggers. Then, a trial of pain desensitization strategies should be marshaled to “wind down” the sensitivity. After pain trigger identification and desensitization, a program of exercises that focuses on specific capability deficits related to the precise demands the person encounters should be the mainstay of rehabilitation. This highly logical approach is on the basis of his considerable research. It is an N = 1 approach that should be considered in an empathetic best practices environment.59
Recent testing of a pain mechanism-based classification system (PMCSs) that includes irritability and psychosocial risk factors as part of a complex hierarchy of clinical decision making has shown promise.91
Alrwaily et al state that PMCSs enable clinicians to observe many clinical indicators of nociceptive, peripheral neuropathic, and central mechanisms to classify patient’s reports of pain.28,92,93,94 The use of classification systems for nonspecific LBP is mainly to improve the outcomes, select appropriate referrals, and guide communication.72,95,96,97 Screening is especially important to identify those patients who are at risk for high service utilization, poor outcomes, or both.98 See also Chapter 7.
Classification is less an, either/or, algorithm than a continuum of both mechanical and central approaches. Much of the time, the focus is on looking for the single best approach for LBP, but because multiple factors contribute, it may be more effective to identify the “dominating” mechanism(s) rather than simply confining potential options to binary thinking (e.g., see Box 4.1).
Box 4.1 Central-Peripheral Continuum | |||||||||||
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The Rationale for Active Care
Because the realization has dawned that there are no “quick fixes” for back pain, there is an increasing realization that teaching patients what to do for themselves—self-management—should be our priority. Is this merely an acceptance of our failure to cure LBP, or is it an acknowledgment of the physician’s ancient role as a teacher and helper?
As a burdensome health condition worldwide, LBP warrants investigation into cost-effective approaches. Increasing knowledge, monitoring of symptoms, and physical activity are consistently recommended in clinical guidelines for LBP management. The potential role of digital health warrants further investigation. However, the digital intervention strategies to support self-management of LBP remain weak.99
Active care adheres to psychosocial principles by providing unambiguous cognitive and behavioral advice to enhance coping ability and motivate patients to gradually resume normal activities. Moreover, there is moderate-to-strong evidence to support the use of psychosocial interventions for pain.100 Patients who worry about their functional status or fear their pain are more likely to have chronic problems.11,67,101 They are particularly vulnerable to being “labeled” with an injured back (i.e., ruptured disc) or degenerative condition.102,103 Similarly, the words used by clinicians with patients have an iatrogenic potential.104,105 Gardner et al found that reinforcement of a cautionary and passive approach from treating physiotherapists may lead to long-term passivity and unhelpful beliefs about activity.106 Patients who expect an activity to be painful or disabling are less likely to perform at a normal level.107,108,109 Thus, one’s performance is limited by psychological as well as physical factors. Stress, muscle tension, and pain are interrelated.12,110 It is the physician’s role to inform the patient that fear and/or stress increase muscle tension, which in turn can exacerbate pain.4 Clinical therapy that incorporates strategies to mitigate fear and/or stress, such as physical, cognitive, and mindfulness-based training, has been shown to reduce fear-avoidance beliefs (FABs) about work-related activity.111 Insight into this relationship helps reassure patients that their pain is largely caused by factors that are potentially controllable.
Active care adheres to biomechanical principles by advising when and how to stabilize the back. LBP is just as likely to occur in individuals who move their back too little as in those who move too much. In fact, a trivial load encountered at a time of vulnerability such as in the early morning or after prolonged sitting is a typical mechanism of injury.112,113,114,115
Active care adheres to neurophysiologic principles by training motor control patterns that are protective of the spine. Spinal instability has been shown to result from poor endurance and coordination of the trunk flexors and extensors.116,117,118,119,120 In particular, low-intensity activation of key stabilization muscles has been shown to enhance joint stiffness and thus stability.116,121 Research shows that agonist-antagonist muscle coactivation is disturbed in LBP patients, thus compromising stability mechanisms involved in reacting to unexpected loads or perturbations.122,123,124,125
Active care adheres to biochemical principles by advising patients to avoid the debilitation of bed rest and inactivity, while encouraging them regarding the safety and value of resuming activities with simple biomechanical modifications. Pain and tissue healing are related to metabolic and nutritional issues. The disc is a relatively hypovascular tissue that contributes to its poor healing ability.126 In fact, some pain treatments such as epidural injections, although they clearly deinflame the nerve root and initially reduce pain, have been shown to cause a rebound pain later, perhaps as a result of interfering with the body’s natural resorption process for the herniated disc.127 Resorption or regression of herniated discs—even in large disc herniations—is a common finding and is consistent with the normal process of tissue repair and remodeling.128,129,130,131,132,133 Further evidence for this is the finding that macrophages are present in high concentration with disc herniations.134,135,136 Inactivity slows the recovery process because the disc is dependent on diffusion for its nutrition.
Rest, inactivity, or overly “guarded” movements are deleterious to the recovery of activity tolerance. Conversely, reassurance that the spine is not injured or damaged and that gradual reactivation will actually speed recovery is necessary to dispel the patient’s disabling feelings and cognitions (i.e., worry, anxiety, and fear).4,5,137,138 A comparative effectiveness meta-analysis by Menke suggests that clinicians who advise patients with chronic LBP to exercise while providing authoritative support can both reduce medicalization and augment self-care.139
The Deconditioning Syndrome: Functional and Cognitive-Behavioral Aspects
The Clinical Examination of Function and Performance
LBP is a subjective symptom that unfortunately correlates poorly with most pathoanatomic (MRI, x-ray) investigations including disc bulges, facet joint degeneration, endplate changes, and mild spondylolisthesis.51,140 Notable exceptions are disc extrusions, moderate or severe canal stenosis, and nerve root compression.140 In fact, most back problems are not caused by structural pathology (arthritis, herniated disc) or serious disease (tumor, infection, fracture) and benefit from prompt reassurance and early, reactivation advice. Therefore, one of the primary goals of care is to reassure patients about the benign nature of their pain and the safety and value of resuming normal activities. Prevention of deconditioning, both physical and psychological, is a fundamental goal of the contemporary management of spinal disorders.
What is deconditioning? Deconditioning is the diminished ability or perceived ability to perform tasks involved in a person’s usual activities of daily living. The plight of clinicians in this field is that because pathoanatomy only correlates weakly with symptoms, there is a dearth of objective findings to aid the clinician in navigating a safe and speedy course for the patient who is recovering slowly. This has led spine scientists to search for relevant, quantifiable features of LBP that do not stifle understanding by overfocusing on pathoanatomic changes.
Measurable abnormalities, whether structural or functional, are considered impairments.54 Historically, impairment was viewed as objective and disability as primarily subjective. However, it is now recognized that impairments (isolated strength/mobility measures) are also related to psychological (cognitive-behavioral) issues such as self-efficacy, fear-avoidance, or pain expectancies, and that disability can at least in part be measured with “subjective” questionnaires (Oswestry, Neck Disability Index) or tests of actual activities (i.e., walking speed, reaching tests, sit-to-stand tests).141 Martinez-Calderon et al published a systematic review of the role of self-efficacy in chronic musculoskeletal pain, and found that evidence consistently supports the correlation between high self-efficacy and lower levels of pain and disability and better physical function, and the negative association between higher self-efficacy and depression.142 Pfingsten et al. found that minimizing the perception of one’s own functional disability actually improves treatment outcomes.143
The World Health Organization has been classifying the consequences of disease, from a biomedical perspective, as impairments, disability, and handicap since 1980.144 This work was updated as the International Classification of Functioning, Disability, and Health (ICF) document, from a biopsychosocial perspective, to take better account of the functional status of the individual.54 The ICF classifies functional status into three interrelated dimensions:
Functions—specific structural and functional impairments
Activities—actions that a person performs/functional limitations
Participation—social or work involvement
Table 4.3 Impairment Versus Disability | ||||||||||||||||||||||||||
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Activity level pertains to functional limitations, whereas impairments are isolated functional deficits (Table 4.3). Functional activities or limitations are further defined as what the patient can or can’t do
(or perceives he or she can’t do!) in his or her daily life (Fig. 4.3). In contrast, specific functional deficits are found only with clinical examination and are often unrelated to the patient’s symptoms or actual functional abilities (e.g., activity level and limitations) (Fig. 4.4).
(or perceives he or she can’t do!) in his or her daily life (Fig. 4.3). In contrast, specific functional deficits are found only with clinical examination and are often unrelated to the patient’s symptoms or actual functional abilities (e.g., activity level and limitations) (Fig. 4.4).
 Figure 4.3 Spinal function sort—carrying a 30-lb bucket 30 feet. Reprinted with permission from Matheson L, Matheson M. Spinal Function Sort. Wildwood, MO: Employment Potential Improvement Corporation; 1989. |
 Figure 4.4 MedX lumbar extension machine. |
Participation is dependent on the physical ability to perform an activity, but it also encompasses social and attitudinal factors. It can be measured with a subset of questions from the Chronic Pain Grading Scale.54,145,146
To what extent did you perform any activities in or around your home during this episode of LBP (not being work or household activities)?
To what extent did you participate in any work and/or household activities during this episode of LBP?
To what extent did you participate in sport activities during this episode of LBP?
To what extent did you participate in any leisure time activities, besides sports, during this episode of LBP?
To what extent did you participate in any social and/or family activities during this episode of LBP?
Each question was answered on a 0 to 10 scale, with 0 indicating “no participation” and 10 indicating “full normal participation.”
What Is the Relationship Between Symptoms, Impairments, Disability, and Distress? Impairments show a tenuous correlation to both pain and activity intolerances (e.g., disability).7,147,148,149 Far from being the so-called objective medical factors, they are related as much to an individual’s motivation to perform as to their actual physical performance ability!108,109,150,151! The American Medical Association’s (AMA)152 guide for assessing physical impairment was updated in 2008 to include a broader array of methods to determine impairment than in previous editions. The 6th edition includes not only spinal range of motion (ROM), but also surgical or radiographic evidence. It also includes a “functional history net modifier” allowing for patient report of functional loss.152 Additional performance attributes have emerged (Table 4.4).
Table 4.4 Performance Attributes Related to Chronic Low Back Pain | |
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Practice-Based Problem
The patient’s goal is to resume activity with less pain. Can the clinician identify impairments that are related to the patient’s symptoms or functional abilities (i.e., disability)? Impairments (i.e., specific dysfunctions) such as hypomobile joints, trigger points, and weak or tight muscles are frequent findings. How do we determine which impairments are clinically relevant?
For instance, can it be determined which impairments are responsible for biomechanical overload (pathomechanics) or are participating in clinically significant functional adaptations or compensations (pathophysiology)? Making this determination is at the heart of shifting care from one that is symptom-based (rest, medication, etc.) to one that is functionally oriented (reassurance, reactivation).
The clinician must be careful not to make the goal of finding and correcting impairments an end in itself. This should be used as a means to achieving the end of symptom reduction and activity restoration.
The most popular measurement of disability (or ability) is a patient’s self-report of activity limitations or perceived functional ability (i.e., Oswestry, Roland-Morris, Neck Disability Index). Although such questionnaires may be reliable and responsive, they do not correlate well with actual measurements of functional performance ability.141,153 Furthermore, they do not measure fundamental work behaviors important for vocational qualification (participation) or specific work behaviors relevant to the question of return to previous work ability (participation).154,155 Thus, questionnaires, although valuable outcomes of care, may not be sufficient guides for determining appropriate treatment strategies or ability to return to work.
Actual testing of functional abilities has been studied.141,156 Simmonds and colleagues have shown how general functional ability can be measured with simple, reliable, inexpensive, time-efficient tests.141,156,157 Examples of such tests include sit-to-stand, rollover tasks, functional reach, loaded reach, distance walked, and so on. These tests are proving to be valuable tools for both identifying functional limitations and establishing realistic goals in the management of LBP patients.45
Matheson and colleagues have shown the continuum from observed signs and symptoms to structural diagnosis, impairments, and the inability to perform specific work behaviors.154,155 Figures 4.5 and 4.6 show the features of this model along with specific measurements used.
 Figure 4.5 Work disability model. Reprinted with permission from Matheson LN. A new model for disability determination. Keynote Address, United Kingdom Society of Occupational Medicine Annual Scientific Meeting; June 2001; Belfast Northern Ireland. |
 Figure 4.6 World Health Organization’s ICF hierarchy. ICF, International Classification of Functioning, Disability, and Health; ROM, range of motion. Modified from Matheson LN. A new model for disability determination. Keynote Address, Work Special Interest Section, American Occupational Therapy Association; April 1999; Indianapolis, IN. |
The relationship between impairment (specific functional deficits), disability (general functional ability, perceived or actual), and pain is poorly understood. Every clinician can think of patients with severe pain and disability who have minimal impairment and others who are very impaired and yet avoid being disabled. Unfortunately, testing ability is more a test of one’s performance than their true capacity, because effort is influenced by pain (actual or expectancy) and psychological factors (fear-avoidance, self-efficacy, affect).79,158,159 Human performance literature indicates that the goals one sets for task performance influence the performance itself.108
Waddell was the first to quantify the relationship between these variables (Fig. 4.7).149 Mannion et al showed that 51.4% of an individual’s disability could be explained by performance, psychological factors, and pain factors (Fig. 4.8).69 The performance factors alone accounted for 24.5% of the variance. Other studies have shown a similar relationship between functional performance deficits and disability.149,160,161,162 Turner et al showed that pain intensity scores measured with a visual analog scale predicted disability as measured with the Roland-Morris questionnaire.163 The authors concluded that back pain rated as 5 or higher is much more likely to be disabling. Swinkels et al also found that pain intensity along with specific pain-related fear significantly predict disability.145
 Figure 4.7 The quantitative relationship between the clinical presentation of pain, disability, and objective physical impairment and the correlation coefficients (r) between them when 0 is no correlation and 1 is complete correspondence. ADL, activities of daily living. Reproduced with permission from Waddell G. The Back Pain Revolution. Edinburgh, Scotland: Churchill Livingstone; 1989. |
 Figure 4.8 Interrelationship between performance, psychological, pain factors, and disability (explained proportion of variance using multiple regression analyses). From Mannion AF, Junge A, Taimela S, Muntener M, Lorenzo K, Dvorak J. Active therapy for chronic low back pain. Part 3. Factors influencing self-rated disability and its change following therapy. Spine. 2001;26:920-929. |
Mannion et al suggests that because one-half of self-reported disability before treatment and more than half of it afterward is unaccounted for by structural, psychological, voluntary performance, or electromyographic
(EMG) fatigue findings, new aspects of physical function relating to motor control are worthy of future investigation.69 These include those aspects of function involved in nonvoluntary, reflex control of movement such as position sense, delayed reaction times, and balance tests listed in Table 4.4.164,165 The next section of this chapter discusses the evidence linking motor control and other functional deficits to spinal disorders.
(EMG) fatigue findings, new aspects of physical function relating to motor control are worthy of future investigation.69 These include those aspects of function involved in nonvoluntary, reflex control of movement such as position sense, delayed reaction times, and balance tests listed in Table 4.4.164,165 The next section of this chapter discusses the evidence linking motor control and other functional deficits to spinal disorders.
Correlation Between Specific Performance Deficits and LBP
The relation between functional deficits or impairments and LBP has been studied extensively. Many features are identified by cross-sectional analysis to be present in greater incidence in pain patients than in asymptomatic patients. However, in such cases, the associated impairment may be a result of pain rather than its cause. A better type of research uses prospective longitudinal analysis, thus providing evidence of the risk of future low back or neck pain when a certain dysfunction is present. Another valuable type of research is to determine if treatment of a specific dysfunction alters patient outcomes. Such research is ideally performed as an RCT.
Isokinetic Strength A reduced ratio of trunk extensor to flexor strength/endurance discriminates between LBP patients and control subjects. The normal ratio is approximately 1.3:1, with the extensors being stronger.166 Mayer and colleagues demonstrated that patients chronically disabled with LBP frequently had a decreased trunk extensor/flexor strength ratio and that a comprehensive, multidisciplinary functional restoration program (including an emphasis on trunk extensor training) successfully returned many of these individuals to work.6
Flexion-Relaxation Phenomena The flexion-relaxation phenomenon occurs when the erector spinae muscles relax involuntarily in terminal stage of a standing trunk flexion maneuver. It has been shown through EMG recordings to correlate with LBP.164,167,168,169 However, despite significant reductions in pain ratings after active therapy, no improvement in flexion-relaxation was found by Mannion.164
Spinal Motion ROM is an integral component in the evaluation of LBP patients.152 Although reliable, its validity is questionable. Various studies have failed to find a correlation between ROM deficits and pain or disability.160 The quality of motion seems more important than its quantity.170 In particular, velocity measurements have shown to be a more valid measure of LBP impairment171 and to correctly predict which asymptomatic manual material handlers would have future LBP.172
Back Muscle Fatigability With EMG This is a unique functional measure because it is involuntary and theoretically not subject to psychophysical issues such as pain expectancy or motivation. Chronic LBP patients show a median frequency shift (increased rate of decline) during sustained contractions that control subjects do not.147,173,174,175 Reliability has been shown to be high when 80% of the maximum voluntary contraction is performed.176 This same finding is reported to correctly predict which asymptomatic manual material handlers will report future LBP.172
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