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Research Review By Dr. Brynne Stainsby©


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Date Posted:

April 2020

Study Title:

Motor control changes in low back pain: Divergence in presentations and mechanisms


van Dieën JH, Reeves NP, Kawchuk G, Van Dillen LR & Hodges PW

Author's Affiliations:

Department of Human Movement Sciences, Vrije Universiteit Amsterdam and Amsterdam Movement Sciences, Amsterdam, the Netherlands; Center for Orthopedic Research, Michigan State University, Lansing, Ml, USA; Osteopathic Surgical Specialties, Michigan State University, USA; Sumaq Life LLC, East Lansing, Ml, USA; Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada; Physical Therapy and Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, MO, USA; Clinical Centre for Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.

Publication Information:

Journal of Orthopaedic & Sports Physical Therapy 2019; 49(6): 370-379.

Background Information:

It has frequently been observed that those with low back pain (LBP) move differently than those without; however, the mechanism of the motor control patterns behind these changes is still not well understood. Motor control is defined as the way in which the nervous system controls posture and movement, including all of the motor, sensory and integrative processes. The quality of the process can be assessed by how well a posture is maintained or a movement is achieved. For example, trunk posture is continuously perturbed by neuromuscular noise, concurrent motor tasks and external mechanical (physical) perturbations (1, 2). Strategies such as anticipatory/feedforward control (3, 4), tonic muscle activity (5-7) and feedback mechanisms based on proprioceptive, visual, tactile and vestibular information (8-11) may be implemented to deal with these perturbations. It is generally believed that those with LBP present with changes in motor control, though the findings thus far are largely inconclusive.

The goals of this commentary are to summarize the current state of the literature regarding the changes in motor control in those with LBP, to propose an interpretation of the variation in motor control changes observed, and to present the clinical implications and considerations for future research.


Motor Control Differences Between individuals with and without Low Back Pain (LBP):
  • With regards to LBP, motor control has been studied not just at the level of the neural structures and processes involved (12-15), but also at the level of the outcomes (that is, the pattern of the trunk muscle activity and movements). Typically, studies of motor control have examined control of the trunk in steady state posture and movement, control of trunk posture and movement when challenged by predictable perturbations (anticipatory/feedforward control) and control of trunk posture and movement with unpredictable perturbations (reactive/feedback control).
  • Studies are inconclusive regarding the effects on muscle activity as a result of injury, nociception or fear of potential pain (16-18). For example, when studying anticipatory activation of trunk muscles prior to limb movement, some studies have found late activation (19-23), some have found early activation (24, 25) and another, no difference (26) when comparing those with LBP to healthy controls.
  • There is also evidence of changes in the structure/morphology of trunk muscles in those with LBP, suggesting the transition from type I to type II muscle fibres (27, 28), atrophy (29-31) and fatty infiltration (32) of the multifidus could affect motor control.
  • Though studies have not demonstrated consistent or clear differences in spine and pelvis alignment between those with and without LBP, those with LBP often display larger postural sway (33), perhaps suggesting reduced balance.
  • Those with LBP typically perform movements more slowly (34), and have been shown to to have more variable trunk movements during gait (35, 36), reaching (37) and repetitive trunk bending (38).
Divergence in Motor Control Features in LBP:

Overall, the literature regarding motor control in LBP is inconsistent. This could be due to a number of factors, including:
  • Methodological variations and small study samples in existing studies.
  • The heterogeneity of LBP as individuals (not to mention the variance in the motor control adaptations – there could be a spectrum of deviations which could affect loading in lumbar tissues).
  • Motor control changes may not be explained by a single factor (ex. changes could be a response to injury or a consequence of ongoing pain, or a purposeful strategy for protection). Explained in a different way – motor control changes may be a cause or consequence of LBP.
  • Two patterns of adaptation have been proposed – one of ‘tight control’ and one of ‘loose control’ – both are outlined below.
Divergent Motor Control Pattern – Tight Control:
  • One pattern of motor control changes has been described as ‘tight control’, which is believed to be the result of increased muscle co-contraction, reflex gains and/or attention to motor control, and likely results in increased tissue loading (39).
  • It is believed that tight control would increase the ‘safety margin’ for control of movement, such that as trunk stiffness is increased, a greater force would be required to perturb the spine.
  • While this approach appears to be protective, it may have negative consequences, such as increased spinal loading. This alone could have varied impact depending on an individual’s mechanical tissue tolerance, level of central sensitization, and so on.
  • Those with LBP have been found to expose the spine to higher loads after perturbation, particularly after less heavy tasks (40). This could result in a cumulative increase in loading, which may increase the risk of injury or pain.
  • Based on animal models, it is also possible that sustained muscle contraction may limit fluid inflow into discs in patients with LBP and impair recovery (41, 42).
  • It is also possible that sustained contraction may lead to fatigue and discomfort of other muscles (43). It may also impair (re)learning of ‘normal’ motor patterns based on decreased variability of trunk muscle recruitment.
  • Although increased stiffness appears to be a helpful strategy to counteract small disturbances, it may compromise an individual’s ability to deal with a larger perturbation (44) or maintain balance on an unstable surface (45, 46).
Divergent Motor Control Pattern – Loose Control:
  • Another possible pattern has been described as ‘loose control’, which is characterized by reduced muscle excitability and avoids high tissue loading.
  • Given the lumbar spine requires control by the surrounding musculature and ligaments, motor control over the spine would be reduced by inhibition of muscle activity or delay in responses to perturbations, resulting in larger amplitude and faster movements, with more variability between repeated performance of the same task.
  • In this pattern, lumbar segments may be compromised, and result in larger tissue strain (47-49).
  • As larger displacements after trunk perturbation have been predictively associated with LBP, it is possible ‘loose control’ patterns may also be a causal factor for LBP.

Clinical Application & Conclusions:

While the literature suggests there may be differences in motor control between those with and without LBP, it demonstrates that not all with LBP demonstrate motor control changes, and not all present in the same way. It is important to remember that individuals affected by LBP are a highly heterogeneous group. For example, as those who have high fear of pain are more likely to stiffen their trunk in anticipation of perturbation than those with LBP with low fear of pain. It is important to recognize that there may be multiple mechanisms contributing to altered motor control, and may also be dependent on the individual and the context.

Injury and nociceptive input are possible stimuli to motor control, and may also be the result of altered motor control. When working with patients, it is important to consider that a change may have occurred as a purposeful strategy to protect from (further) injury, and this may impact a patient’s response to care.

Considering the negative consequences of a patient’s control pattern may help to direct strategies. For example, in those who demonstrate tight control patterns, aiming to reduce muscular excitability and co-contraction, and increasing movement and movement variations (50) may be very helpful, while those who demonstrate loose control may require strategies to increase motor control (50). It is important to recall that future research is required to validate assessment tools and therapeutic strategies in this domain, and clinicians should consider short trials of care with careful explanations to patients in order to ensure that goals and expectations are monitored and met.

Study Methods:

This was a clinical commentary and thus, did not report methodology.

Study Strengths / Weaknesses:

  • This commentary summarizes theoretical constructs related to the motor control changes in LBP in a well organized, well described manner.
  • The authors carefully identify the limitations in the literature and caution readers from drawing unsupported conclusions.
  • The authors also helpfully identify the fact that this field literature is characterized by inconsistency in findings, and rightfully suggest that differences in methodology may account for some of the inconsistencies, however, the variation between patients with LBP must also be considered.
  • Clinical suggestions for multimodal treatment approaches are provided.
  • The greatest weakness of this study is the lack of methodology reported. Without this, we cannot be confident that the conclusions were not subject to high risk of bias.
  • While this article provides a summary of the literature included, there is no assessment of the methodology or research quality. The authors included a number of preliminary and animal studies, and the majority of the studies are cross-sectional in nature, which do not allow us to identify if the change in motor control cause LBP, or vice versa.
  • There is no comment on the participants or clinical setting of the included studies, thus limiting the external validity of the review.

Additional References:

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