Diverse Role of Biological Plasticity in Low Back Pain and Its Impact on Sensorimotor Control of the Spine

Persistence, not avoidance, is associated with low back pain-An observational cohort study

BACKGROUND

Low back pain (LBP) is increasingly understood as a long-lasting condition with a variable course. Avoidance and persistence behaviour have been described to mediate pain persistence by potentially linking psychosocial factors and biomechanics. The resulting maladaptive changes in musculoskeletal structures can result in movement control impairment (MCI). This investigation aimed to observe avoidance and persistence behaviour and MCI in participants with acute LBP over 1 year and explore their association with pain persistence.

METHODS

In this observational cohort study, 165 participants were assessed at five time points: ≤ 1 month (baseline), 2, 3, 6, and 12 months after the onset of acute LBP. Simultaneously collected clinical data such as self-reported outcomes at baseline for avoidance and persistence and assessments of MCI were filled in linear mixed-effects regression models.

RESULTS

The mixed-effects analysis revealed for the adjusted model that a one-point increase in persistence scores resulted in a 3.31-point increase in pain intensity while interacting with state anxiety over time (p = 0.05, 95% confidence interval 0.07-6.07). This effect was not found for avoidance behaviour at baseline (p = 0.21) and MCI.

CONCLUSIONS

The relationship between persistence and pain intensity throughout measurement suggests that continuing usual activities beyond pain, coupled with feelings of distress, may lead to persistent LBP. These results underscore the need for a therapeutic shift toward a multidimensional approach that considers the physical and psychological characteristics of persons with LBP. Screening for activity patterns in acute LBP is critical for providing tailored treatment and counselling.

SIGNIFICANCE STATEMENT

In acute low back pain (LBP), maintaining usual activities despite pain and distress can contribute to the continuation of LBP. Alongside a multidimensional approach that considers physical and psychological factors, attitudes toward daily activities are also important. Screening for both maladaptive and adaptive activity patterns in individuals with acute LBP is essential for effective LBP management, improving patient outcomes, and preventing persistent pain.

Neuroinflammatory activation in sensory and motor regions of the cortex is related to sensorimotor function in individuals with low back pain maintained by nociplastic mechanisms: A preliminary proof-of-concept study

BACKGROUND

Chronic pain involves communication between neural and immune systems. Recent data suggest localization of glial (brain immune cells) activation to the sensorimotor regions of the brain cortex (S1/M1) in chronic low back pain (LBP). As glia perform diverse functions that impact neural function, activation might contribute to sensorimotor changes, particularly in LBP maintained by increased nervous system sensitivity (i.e., nociplastic pain). This preliminary proof-of-concept study aimed to: (i) compare evidence of neuroinflammatory activation in S1/M1 between individuals with and without LBP (and between nociceptive and nociplastic LBP phenotypes), and (ii) evaluate relationships between neuroinflammatory activation and sensorimotor function.

METHODS

Simultaneous PET-fMRI measured neuroinflammatory activation in functionally defined S1/M1 in pain-free individuals (n = 8) and individuals with chronic LBP (n = 9; nociceptive: n = 4, nociplastic: n = 5). Regions of S1/M1 related to the back were identified using fMRI during motor tasks and thermal stimuli. Sensorimotor measures included single and paired-pulse transcranial magnetic stimulation (TMS) and quantitative sensory testing (QST). Sleep, depression, disability and pain questionnaires were administered.

RESULTS

Neuroinflammatory activation was greater in the lower back cortical representation of S1/M1 of the nociplastic LBP group than both nociceptive LBP and pain-free groups. Neuroinflammatory activation in S1/M1 was positively correlated with sensitivity to hot (r = 0.52) and cold (r = 0.55) pain stimuli, poor sleep, depression, disability and BMI, and negatively correlated with intracortical facilitation (r = -0.41).

CONCLUSION

This preliminary proof-of-concept study suggests that neuroinflammation in back regions of S1/M1 in individuals with nociplastic LBP could plausibly explain some characteristic features of this LBP phenotype.

SIGNIFICANCE STATEMENT

Neuroinflammatory activation localized to sensorimotor areas of the brain in individuals with nociplastic pain might contribute to changes in sensory and motor function and aspects of central sensitization. If cause-effect relationships are established in longitudinal studies, this may direct development of therapies that target neuroinflammatory activation.

Sex Differences in the Serum Proteomic Profile During Acute Low Back Pain-A Preliminary Study of the Relationship to Future Low Back Pain

The molecular processes driving the transition from acute to chronic low back pain (LBP) remain poorly understood and are likely to be sexually dimorphic. This study aimed to explore sex differences in the serum proteomic profile of people experiencing an acute LBP episode and determine if serum protein concentrations were associated with three-month outcome. Serum samples were collected through venepuncture from 30 female and 29 male participants experiencing an acute LBP episode. Serum samples underwent trypsin digestion and fractionation using hydrophobic interaction chromatography and were then analysed using mass-spectrometry. Mass-spectrometry spectra were searched in the Swissprot database for protein identification. Sex differences in protein abundance changes were evident upon inspection of fold changes. Multivariable data analysis identified 21 serum proteins during the acute episode that correctly classified 93% of males and 23 serum proteins that correctly classified 90% of females with ongoing LBP at 3 months. Pathway analysis suggested the differentially expressed proteins during acute LBP were frequently involved in immune, inflammatory, complement, or coagulation responses. This data provides preliminary evidence that biological processes during an acute LBP episode may contribute to the resolution, or persistence, of LBP symptoms at 3 months, however, these processes differ between males and females. PERSPECTIVE: Differential expression of serum proteins was observed between male and female participants during an acute LBP episode. This preliminary work provides a foundation for future research targeting distinct immune system processes in males and females that may interfere with the transition from acute to chronic LBP.

Testing Biological and Psychological Pathways of Emotion Regulation as a Primary Mechanism of Action in Yoga Interventions for Chronic Low Back Pain: Protocol for a Randomized Controlled Trial

BACKGROUND

Interventions that promote adaptive emotion regulation (ER) skills reduce pain in patients with chronic pain; however, whether the effects of yoga practice on chronic low back pain (CLBP) are due to improvements in ER remains to be examined.

OBJECTIVE

This study will test whether the effects of yoga on CLBP (improved pain severity and interference) are mediated by improved ER, the extent to which effects are related to specific aspects of ER, and the role of pain sensitization as a mediator or moderator of effects. In this study, pain sensitization will be assessed by quantitative sensory testing and gene expression profiles to examine whether pain sensitization moderates yoga's effects on pain or whether yoga and ER abilities reduce pain sensitization, leading to decreased pain severity and interference.

METHODS

For this 2-arm parallel group blinded randomized controlled trial, we will enroll 204 adults with CLBP who will be randomized to receive the yoga (n=102) or a control stretching and strengthening (n=102) intervention, which are delivered via web-based synchronous biweekly 75-minute sessions over 12 weeks. Participants are encouraged to practice postures or exercises for 25 minutes on other days using accessible prerecorded practice videos that are sent to participants digitally. Participants will be assessed at 5 time points: baseline, midintervention (6 weeks), postintervention (12 weeks), and 3- and 6-month follow-ups. Assessments of ER, pain severity and interference, pain sensitivity including somatosensory and gene expression profiles, and physical strength and flexibility will be conducted at each visit. The fidelity of the interventions is assessed using a manualized checklist to evaluate recorded group sessions to ensure consistent instructor delivery.

RESULTS

The primary outcome will be the mean change in pain severity as measured by the Brief Pain Inventory-Short Form at 12 weeks. The primary mechanism of action is ER measured by change in the Difficulties in Emotion Regulation Scale total score. Secondary outcomes include pain sensitivity, physical strength and flexibility, pain interference, and quality of life. A mediation path analysis and series of moderated mediation path analyses will be conducted to test the study hypotheses. As of January 2024, we have enrolled 138 participants. We expect the study to be completed by May 2025.

CONCLUSIONS

The study will provide important data for evaluating whether improvements in ER are responsible for reduced pain perception and pain sensitivity as well as increased quality of life in the context of chronic pain. The study findings have important implications for determining the mechanism of action for yoga and possibly other mind-body interventions as nonpharmacological therapies for pain management. The results of the study will inform the content, delivery, and measures for intervention trials involving yoga as a modality for relieving pain and improving function.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04678297; https://clinicaltrials.gov/study/NCT04678297.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56016.

Annulus Fibrosus Injury Induces Acute Neuroinflammation and Chronic Glial Response in Dorsal Root Ganglion and Spinal Cord-An In Vivo Rat Discogenic Pain Model

Chronic painful intervertebral disc (IVD) degeneration (i.e., discogenic pain) is a major source of global disability needing improved knowledge on multiple-tissue interactions and how they progress in order improve treatment strategies. This study used an in vivo rat annulus fibrosus (AF) injury-driven discogenic pain model to investigate the acute and chronic changes in IVD degeneration and spinal inflammation, as well as sensitization, inflammation, and remodeling in dorsal root ganglion (DRG) and spinal cord (SC) dorsal horn. AF injury induced moderate IVD degeneration with acute and broad spinal inflammation that progressed to DRG to SC changes within days and weeks, respectively. Specifically, AF injury elevated macrophages in the spine (CD68) and DRGs (Iba1) that peaked at 3 days post-injury, and increased microglia (Iba1) in SC that peaked at 2 weeks post-injury. AF injury also triggered glial responses with elevated GFAP in DRGs and SC at least 8 weeks post-injury. Spinal CD68 and SC neuropeptide Substance P both remained elevated at 8 weeks, suggesting that slow and incomplete IVD healing provides a chronic source of inflammation with continued SC sensitization. We conclude that AF injury-driven IVD degeneration induces acute spinal, DRG, and SC inflammatory crosstalk with sustained glial responses in both DRGs and SC, leading to chronic SC sensitization and neural plasticity. The known association of these markers with neuropathic pain suggests that therapeutic strategies for discogenic pain need to target both spinal and nervous systems, with early strategies managing acute inflammatory processes, and late strategies targeting chronic IVD inflammation, SC sensitization, and remodeling.

Comparison of psoas major activation during standing hip flexion between chronic low back pain and healthy populations

BACKGROUND

The psoas major (PM) has been identified as a potential contributor to chronic low back pain (LBP). However, few studies have investigated the effects of upright functional movement on PM activation in cLBP individuals.

OBJECTIVE

This cross-sectional study aims to compare PM muscle activation characteristics in chronic LBP (cLBP) and healthy subjects during the transition from quiet double-leg standing to standing hip flexion.

METHODS

Ultrasound Imaging was used to assess PM thickness at the lumbar vertebral level of L4-5 in 12 healthy and 12 cLBP participants. The changes in thickness between the test positions were utilized as a proxy for PM activation.

RESULTS

The cLBP group exhibited greater thickness changes on the non-dominant side PM during contralateral hip flexion but not ipsilateral hip flexion (p= 0.369) compared to their healthy counterparts (p= 0.011; cLBP: resting 27.85 mm, activated 34.63 mm; healthy: resting 29.51 mm, activated 29.00 mm). There were no significant differences in dominant side PM thickness changes between the two groups during either contralateral or ipsilateral hip flexion (p= 0.306 and p= 0.077).

CONCLUSION

Our findings suggest a potential overactivation of the PM in the cLBP population. This insight may aid in the development of tailored rehabilitation programs.

Pulsed Red and Blue Photobiomodulation for the Treatment of Thigh Contusions and Soft Tissue Injury: A Randomized Controlled Trial

CONTEXT

Contusion and soft tissue injuries are common in sports. Photobiomodultion, light and laser therapy, is an effective aid to increase healing rates and improve function after various injury mechanisms. However, it is unclear how well photobiomodulation improves function after a contusion soft tissue injury. This study aimed to determine the effects of a pulsed red and blue photobiomodulation light patch on muscle function following a human thigh contusion injury.

DESIGN

Single-blinded randomized control trial design.

METHODS

We enrolled 46 healthy participants. Participants completed 5 visits on consecutive days. On the first visit, participants completed a baseline isokinetic quadriceps strength testing protocol at 60°/s and 180°/s. On the second visit, participants were struck in the rectus femoris of the anterior thigh with a tennis ball from a serving machine. Immediately following, participants were treated for 30 minutes with an active or placebo photobiomodulation patch (CareWear light patch system, CareWear Corp). Following the treatment, participants completed the same isokinetic quadriceps strength testing protocol. Participants completed the treatment and isokinetic quadriceps strength test during the following daily visits. We normalized the data by calculating the percent change from baseline. We used a mixed model analysis of covariance, with sex as a covariate, to determine the difference between treatment groups throughout the acute recovery process.

RESULTS

We found the active photobiomodulation treatment significantly increased over the placebo group, quadriceps peak torque during the 180°/s test (P = .030), and average power during both the 60°/s (P = .041) and 180°/s (P ≤ .001) assessments. The mean peak torque and average power of 180°/s, at day 4, exceeded the baseline levels by 8.9% and 16.8%, respectively.

CONCLUSIONS

The red and blue photobiomodulation light patch improved muscle strength and power during the acute healing phase of a human thigh contusion injury model.

Multifidus dysfunction and restorative neurostimulation: a scoping review

OBJECTIVE

Chronic low back pain (CLBP) is multifactorial in nature, with recent research highlighting the role of multifidus dysfunction in a subset of nonspecific CLBP. This review aimed to provide a foundational reference that elucidates the pathophysiological cascade of multifidus dysfunction, how it contrasts with other CLBP etiologies and the role of restorative neurostimulation.

METHODS

A scoping review of the literature.

RESULTS

In total, 194 articles were included, and findings were presented to highlight emerging principles related to multifidus dysfunction and restorative neurostimulation. Multifidus dysfunction is diagnosed by a history of mechanical, axial, nociceptive CLBP and exam demonstrating functional lumbar instability, which differs from other structural etiologies. Diagnostic images may be used to grade multifidus atrophy and assess other structural pathologies. While various treatments exist for CLBP, restorative neurostimulation distinguishes itself from traditional neurostimulation in a way that treats a different etiology, targets a different anatomical site, and has a distinctive mechanism of action.

CONCLUSIONS

Multifidus dysfunction has been proposed to result from loss of neuromuscular control, which may manifest clinically as muscle inhibition resulting in altered movement patterns. Over time, this cycle may result in potential atrophy, degeneration and CLBP. Restorative neurostimulation, a novel implantable neurostimulator system, stimulates the efferent lumbar medial branch nerve to elicit repetitive multifidus contractions. This intervention aims to interrupt the cycle of dysfunction and normalize multifidus activity incrementally, potentially restoring neuromuscular control. Restorative neurostimulation has been shown to reduce pain and disability in CLBP, improve quality of life and reduce health care expenditures.

Durable patient-reported outcomes following 60-day percutaneous peripheral nerve stimulation (PNS) of the medial branch nerves

Background

Chronic low back pain (CLBP) is often associated with clinical evidence of central nervous system sensitization and finding a clear source of nociceptive input can be challenging. Conventional therapies targeting peripheral spinal pain structures can fail to address centrally-mediated, underlying causes of pain. Sixty-day percutaneous peripheral nerve stimulation (PNS) applied to the lumbar medial branch nerves is a non-surgical, non-opioid treatment that may restore the balance of peripheral inputs to the central nervous system and reverse maladaptive changes in central pain processing. As a minimally invasive, non-destructive treatment, percutaneous PNS was designed to be used earlier in the treatment continuum than radiofrequency ablation or permanently-implanted neurostimulation systems.

Objective

The objective of this clinical trial was to characterize the durability of responses to medial branch PNS in a prospective multicenter case series study of CLBP patients recalcitrant to multiple non-surgical treatments.

Design

Prospective, multicenter clinical trial.

Population

Adults with CLBP without radicular leg pain who had previously failed multiple types of conventional treatments.

Intervention

Sixty-day percutaneous PNS applied to the lumbar medial branch nerves.

Methods

Percutaneous PNS leads were implanted under image guidance (ultrasound and/or fluoroscopy) and treatment was applied for up to 60 days, after which the leads were removed. Participants were followed through 14 months (12 months after the 2-month PNS treatment). Prospectively-defined endpoints included assessments of pain intensity, disability, pain interference, health-related quality of life, depression, and patient global impression of change.

Results

Treatment of CLBP with 60-day percutaneous PNS treatment produced clinically meaningful improvements in average pain intensity, disability, and/or pain interference for a majority of participants through the entire 14 month follow up period without requiring permanent system implantation. The proportion of participants experiencing clinically meaningful improvement in at least one outcome (pain intensiy, disability, pain interference) with PNS was 91% after 2 months, 79% at 5 months, 73% at 8 months, 75% at 11 months, and 77% at 14 months. There were no serious or unanticipated study-related adverse events.

Conclusion

This prospective multicenter clinical trial demonstrates the clinical utility of percutaneous PNS when applied to the medial branch nerves for the treatment of chronic low back pain recalcitrant to non-surgical treatments. Given the minimally invasive nature of percutaneous PNS and the significant benefits experienced by participants, percutaneous PNS provides a safe and effective first-line neuromodulation treatment for patients with CLBP that may obviate the need for neuroablative procedures or permanent neurostimulation system implantation.

Investigation of the relationship between the clinical evaluation results of lumbar region muscles with cross-sectional area and fat infiltration

BACKGROUND

The relationship between the endurance of the lumbar paraspinal muscles and morphological changes needs to be clarified. In this context, the importance can be revealed of increasing the endurance level of the paraspinal muscles in the prevention and treatment of low back diseases.

OBJECTIVE

The aim of this study was to examine the relationship between the clinical evaluation results of the cross-sectional area (CSA) and fat infiltration of the lumbar deep paraspinal muscles.

METHODS

The study included 37 patients with mechanical low back pain (mechanical), 41 patients with lumbar hernia without root compression (discopathy) and 36 healthy individuals as a control group. The functional status of the lumbar deep paraspinal muscles was evaluated clinically with muscle endurance tests. The fat infiltration and CSA of the muscles were evaluated on axial MRI sections at the L3-S1 level.

RESULTS

The mean values of the prone bridge, Biering-Sorenson, and trunk flexion tests were seen to be highest in the control group and lowest in the discopathy group (p< 0.001). In all tests, the longest test period was obtained at < 10% fat infiltration and the shortest at > 50% fat infiltration. It was observed that as the amount of fat infiltration of the muscles increased, the test times were shortened. There was no significant relationship between the endurance level and the CSA of the groups.

CONCLUSION

The study results demonstrated that the endurance of the paraspinal muscles is associated with the fat infiltration of the muscles. In patients with chronic low back pain, information about muscle morphology and degeneration can be obtained with simple endurance tests without the need for further measurements. On clinical examination, a weak endurance level of the paraspinal muscles indicates the presence of a low back problem and an increase in the amount of fat infiltration.

Does Preoperative Symptom Duration Impact Clinical Outcomes After Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Setting?

BACKGROUND

The effect of prolonged symptom duration in patients undergoing ambulatory MIS-TLIF on postoperative clinical outcomes has not been well studied. We aim to compare symptom duration of pain and/or weakness on postoperative outcomes in patients undergoing outpatient MIS-TLIF.

METHODS

Patients undergoing outpatient MIS-TLIF were gathered in a single-surgeon database. Exclusion criteria were patients missing onset of symptoms, date of surgery, or diagnosis of malignancy, trauma, or infection. Patients were grouped by symptoms <1 year or symptoms ≥1 year. Propensity score matching for demographics was utilized. Minimal clinically important difference (MCID) achievement was calculated by comparing change in patient-reported outcome measures (PROMs) to previously established values. Inferential statistics for demographics, perioperative characteristics, PROMs, and MCID were utilized to compare between groups and/or postoperative improvement.

RESULTS

After matching, there were a total of 56 patients, with 30 patients with symptoms <1-year. The <1-year cohort reported significant improvement in all time points in VAS back/leg and 12-week/6-months in ODI. The ≥1-year cohort demonstrated significant improvement in 6-month Patient-Reported Outcomes Measurement-Information System Physical Function, 6-week to 1-year VAS back, 6-week VAS leg, and 6-month ODI. The <1-year cohort had higher MCID attainment rates in 1-year VAS back/leg.

CONCLUSIONS

Independent of symptom duration, patients reported significant improvement in back pain at all postoperative periods. Patients presenting with shorter symptom duration consistently reported significant improvement in leg pain postoperatively. Patients with shorter symptom duration demonstrated greater MCID achievement in back and leg pain. Patients indicated for outpatient MIS-TLIF may benefit more from earlier intervention following onset of symptoms.

Sling Exercise Can Drive Cortical Representation of the Transversus Abdominis and Multifidus Muscles in Patients With Chronic Low Back Pain

Objective

The transversus abdominis (TrA) and multifidus (MF) muscles are essential in preventing chronic low back pain (CLBP) recurrence by maintaining segmental stabilization and stiffness. Sling exercise is a high-level core stability training to effectively improve the activities of the TrA and MF muscles. However, the neural mechanism for sling exercise-induced neural plasticity change in the primary motor cortex (M1) remains unclear. This study aimed to investigate the role of sling exercise in the reorganization of the motor cortical representation of the TrA and MF muscles.

Methods

Twenty patients with CLBP and 10 healthy individuals were recruited. For map volume, area, the center of gravity (CoG) location (medial-lateral location and anterior-posterior location), and latency, two-way ANOVA was performed to compare the effects of groups (the CLBP-pre, CLBP-post, and healthy groups) and the two muscles (the TrA and MF muscles). The Visual Analog Scale (VAS), the Oswestry Disability Index (ODI), and postural balance stability were assessed at baseline and at the end of 2 weeks of sling exercise. Linear correlations between VAS or ODI and CoG locations were assessed by Pearson's correlation test.

Results

2 weeks of sling exercise induced both the anterior-medial (P &lt; 0.001) and anterior-posterior (P = 0.025) shifts of the MF muscle representation at the left motor cortex in patients with CLBP. Anterior-medial (P = 0.009) shift of the TrA muscle representation at the right motor cortex was observed in patients with CLBP. The motor cortical representation of the two muscles in patients with CLBP after sling exercise (TrA: 2.88 ± 0.27 cm lateral and 1.53 ± 0.47 cm anterior of vertex; MF: 3.02 ± 0.48 cm lateral and 1.62 ± 0.40 cm anterior of vertex) closely resembled that observed in healthy individuals (TrA: 2.83 ± 0.48 cm lateral and 2.00 ± 0.43 cm anterior of vertex; MF: 2.94 ± 0.43 cm lateral and 1.77 ± 0.48 cm anterior of vertex). The VAS and the ODI were reduced following the sling exercise (VAS: P &lt; 0.001; ODI: P &lt; 0.001).

Conclusion

This study provides evidence that sling training can drive plasticity changes in the motor system, which corresponds with the reduction in pain and disability levels in patients with CLBP. This study was registered in the Chinese Clinical Trial Registry (Clinical Trial Registration Number: ChiCTR2100045904, http://www.chictr.org.cn/showproj.aspx?proj=125819).

Clinical Trial Registration

ChiCTR2100045904.

Perturbation-based trunk stabilization training in elite rowers: A pilot study

Introduction

Low back pain is a major health issue in elite rowers. High training volume, frequent flexion movements of the lower spine and rotational movement in sweep rowing contribute to increased spinal strain and neuropathological patterns. Perturbation-based trunk stabilization training (PTT) may be effective to treat neuromuscular deficits and low back pain.

Methods

All boat classes (8+, 4+/-, 2-) of the male German national sweep rowing team participated in this non-randomized parallel group study. We included 26 athletes (PTT: n = 12, control group: n = 14) in our analysis. Physical and Sports therapists conducted 16 individualized PTT sessions á 30–40 minutes in 10 weeks, while the control group kept the usual routines. We collected data before and after intervention on back pain intensity and disability, maximum isometric trunk extension and flexion, jump height and postural sway of single-leg stance.

Results

We found less disability (5.3 points, 95% CI [0.4, 10.1], g = 0.42) for PTT compared to control. Pain intensity decreased similar in both groups (-14.4 and -15.4 points), yielding an inconclusive between-group effect (95% CI [-16.3, 14.3]). Postural sway, strength and jump height tend to have no between- and within-group effects.

Conclusion

Perturbation-based trunk stabilization training is possibly effective to improve the physical function of the lower back in elite rowers.

Treatment of chronic axial back pain with 60-day percutaneous medial branch PNS: Primary end point results from a prospective, multicenter study

Background

The objective of this prospective, multicenter study is to characterize responses to percutaneous medial branch peripheral nerve stimulation (PNS) to determine if results from earlier, smaller single‐center studies and reports were generalizable when performed at a larger number and wider variety of centers in patients recalcitrant to nonsurgical treatments.

Materials & Methods

Participants with chronic axial low back pain (LBP) were implanted with percutaneous PNS leads targeting the lumbar medial branch nerves for up to 60 days, after which the leads were removed. Participants were followed long‐term for 12 months after the 2‐month PNS treatment. Data collection is complete for visits through end of treatment with PNS (primary end point) and 6 months after lead removal (8 months after start of treatment), with some participant follow‐up visits thereafter in progress.

Results

Clinically and statistically significant reductions in pain intensity, disability, and pain interference were reported by a majority of participants. Seventy‐three percent of participants were successes for the primary end point, reporting clinically significant (≥30%) reductions in back pain intensity after the 2‐month percutaneous PNS treatment (n = 54/74). Whereas prospective follow‐up is ongoing, among those who had already completed the long‐term follow‐up visits (n = 51), reductions in pain intensity, disability, and pain interference were sustained in a majority of participants through 14 months after the start of treatment.

Conclusion

Given the minimally invasive, nondestructive nature of percutaneous PNS and the significant benefits experienced by participants who were recalcitrant to nonsurgical treatments, percutaneous PNS may provide a promising first‐line neurostimulation treatment option for patients with chronic axial back pain.

The contemporary model of vertebral column joint dysfunction and impact of high-velocity, low-amplitude controlled vertebral thrusts on neuromuscular function

Purpose

There is growing evidence that vertebral column function and dysfunction play a vital role in neuromuscular control. This invited review summarises the evidence about how vertebral column dysfunction, known as a central segmental motor control (CSMC) problem, alters neuromuscular function and how spinal adjustments (high-velocity, low-amplitude or HVLA thrusts directed at a CSMC problem) and spinal manipulation (HVLA thrusts directed at segments of the vertebral column that may not have clinical indicators of a CSMC problem) alters neuromuscular function.

Methods

The current review elucidates the peripheral mechanisms by which CSMC problems, the spinal adjustment or spinal manipulation alter the afferent input from the paravertebral tissues. It summarises the contemporary model that provides a biologically plausible explanation for CSMC problems, the manipulable spinal lesion. This review also summarises the contemporary, biologically plausible understanding about how spinal adjustments enable more efficient production of muscular force. The evidence showing how spinal dysfunction, spinal manipulation and spinal adjustments alter central multimodal integration and motor control centres will be covered in a second invited review.

Results

Many studies have shown spinal adjustments increase voluntary force and prevent fatigue, which mainly occurs due to altered supraspinal excitability and multimodal integration. The literature suggests physical injury, pain, inflammation, and acute or chronic physiological or psychological stress can alter the vertebral column’s central neural motor control, leading to a CSMC problem. The many gaps in the literature have been identified, along with suggestions for future studies.

Conclusion

Spinal adjustments of CSMC problems impact motor control in a variety of ways. These include increasing muscle force and preventing fatigue. These changes in neuromuscular function most likely occur due to changes in supraspinal excitability. The current contemporary model of the CSMC problem, and our understanding of the mechanisms of spinal adjustments, provide a biologically plausible explanation for how the vertebral column’s central neural motor control can dysfunction, can lead to a self-perpetuating central segmental motor control problem, and how HVLA spinal adjustments can improve neuromuscular function.

Cortical Representations of Transversus Abdominis and Multifidus Muscles Were Discrete in Patients with Chronic Low Back Pain: Evidence Elicited by TMS

Introduction

The transversus abdominis (TVA) and multifidus (MF) muscles are the main segmental spinal stabilizers that are controlled by the primary motor cortex of the brain. However, relocations of the muscle representation in the motor cortex may occur after chronic lower back pain (cLBP); it still needs more evidence to be proven. The current study was aimed at applying transcranial magnetic stimulation (TMS) to investigate the changes of representation of TVA and MF muscles at the cortical network in individuals with cLBP.

Methods

Twenty-four patients with cLBP and 12 age-matched healthy individuals were recruited. Responses of TVA and MF to TMS during muscle contraction were monitored and mapped over the contralateral cortex using a standardized grid cap. Maps of the center of gravity (CoG), area, volume, and latency were analyzed, and the asymmetry index was also computed and compared.

Results

The locations of MF CoG in cLBP individuals were posterior and lateral to the CoG locations in healthy individuals. In the healthy group, the locations of TVA and MF CoG were closed to each other in both the left and right hemispheres. In the cLBP group, these two locations were next to each other in the right hemisphere but discrete in the left hemisphere. In the cLBP group, the cortical motor map of TVA and MF were mutually symmetric in five out of eleven (45.5%) subjects and leftward asymmetric in four out of ten (40.0%) subjects.

Conclusions

Neural representations of TVA and MF muscles were closely organized in both the right and left motor cortices in the healthy group but were discretely organized in the left motor cortex in the cLBP group. This provides strong support for the neural basis of pathokinesiology and clinical treatment of cLBP.

Force dependent effects of chronic overuse on fibrosis-related genes and proteins in skeletal muscles

AIM

To examine the chronic effect of force on mRNA and protein expression levels of fibrosis-related genes in flexor digitorum muscles in a rat model of repetitive overuse injury that induces muscle fibrosis at high force levels.

MATERIALS AND METHODS

Two groups of rats were trained to perform a voluntary repetitive lever-pulling task at either a high (HFHR) or a low force (LFHR) for 18 weeks, while a control group (FRC) performed no task. RNA and protein were prepared from forelimb flexor digitorum muscles. Fibrosis-related gene RNA transcripts were evaluated using quantitative PCR (qPCR) and analyzed using the geometric mean of three housekeeping genes or the mean of each individually as reference. Protein levels were quantified using ELISA, western blot, or immunohistofluorescence.

RESULTS

Of eight fibrosis-related mRNAs examined, only FGF2 demonstrated a consistent significant increase in the HFHR group, compared to the FRC group. However, protein amounts of collagen type 1, collagen type 3, and TGFβ1 were significantly higher in the HFHR, compared to the FRC and LFHR groups, while CCN2 and FGF2 were higher in both HFHR and LFHR, compared to the FRC group.

CONCLUSIONS

Our results suggest that there is steady-state transcription of fibrogenic genes in muscles with established fibrosis, implying that post-transcriptional processes are responsible for the increased protein levels of fibrotic factors during muscle overuse conditions. We hypothesize that targeting such pathways represents a valid approach to treat overuse injury. Alternatively, FGF2 gene expression may represent a valid target for therapy.

The Pelvic Girdle Pain deadlock: 2. Topics that, so far, have remained out of focus

INTRODUCTION

In our preceding paper, we concluded that Pelvic Girdle Pain (PGP) should be taken seriously. Still, we do not know its causes. Literature reviews on treatment fail to reveal a consistent pattern, and there are patients who do not respond well to treatment. We designated the lack of progress in research and in the clinic as 'deadlock', and proposed a 'deconstruction' of PGP, that is to say, taking PGP apart into its relevant dimensions.

PURPOSE

We examine the proposition that PGP may emerge as local inflammation. Inflammation would be a new dimension to be taken into account, between biomechanics and psychology. To explore the consequences of this idea, we present four different topics that, so far, have remained out of focus. One: The importance of microtrauma. Two: Ways to counteract chronification. Three: The importance of sickness behaviour when systemic inflammation turns into neuroinflammation of the brain. And Four: The mainly emotional and cognitive nature of chronic pain, and how aberrant neuroinflammation may render chronic pain intractable. For intractable pain, sleep and stress management are promising treatment options.

IMPLICATIONS

The authors hope that the present paper helps to stimulate the flexible creativity that is required to deal with the biological and psychological impact of PGP. Measuring inflammatory mediators in PGP should be a research priority. It should be understood that the boundaries between biology and psychology are becoming blurred. Clinicians must frequently monitor pain, disability, and mood, and be ready to switch treatment whenever the patient does not improve.

Tactile acuity and predominance of central sensitization in subjects with non-specific persistent low back pain

Aim: This study aimed to evaluate differences in tactile acuity (TA) in people with non-specific persistent low back pain (NSPLBP) with and without predominant central sensitisation (CS).Method: An analytical cross-sectional study was conducted with 45 participants divided into three groups: (i) subjects with NSPLBP with predominant CS (n = 14), (ii) subjects with NSPLBP without predominant CS (n = 16) and (iii) subjects without low back pain (n = 15). Using an analogue calliper, TA was measured using the two-point discrimination threshold (TPD) in the three groups, both horizontally and vertically in the painful region. The analysis was based on the comparison of median discrimination thresholds between groups using the Kruskal-Wallis test.Result: A higher median TPD value was observed in the group with NSPLBP with predominant CS (vertical measurement 37.5 mm; horizontal measurement 52.5 mm) compared to the group with NSPLBP without predominant CS (vertical measurement 32.5 mm; horizontal measurement 33.8 mm) and the group without low back pain (vertical measurement 30 mm; horizontal measurement 27.5 mm) (p < 0.0001), both in vertical and horizontal measurement.Conclusion: The findings found in this study highlight the need to differentiate patients with NSPLBP with predominant CS when considering therapeutic evaluation as an indirect mechanism for assessing the perceptual function of the primary somatosensory cortex.

The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain

Low-back pain (LBP) is one of the most burdensome health problems in the world. Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes, particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised physiotherapy has the potential of being more effective for people with LBP; however, there is limited evidence supporting this approach. A series of studies supporting the mechanisms underpinning and effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised physiotherapy have been published. The clinical and research implications of these findings are presented and discussed. Treatment based on the STOPS approach should also be considered as an approach to individualised physiotherapy in people with LBP.

Can Biomechanics Research Lead to More Effective Treatment of Low Back Pain? A Point-Counterpoint Debate

SYNOPSIS

Although biomechanics plays a role in the development and perhaps the persistent or recurrent nature of low back pain (LBP), whether biomechanics alone can provide the basis for intervention is debated. Biomechanics, which refers to the mechanics of the body, including its neuromuscular control, has been studied extensively in LBP. But, can gains be made in understanding LBP by research focused on this component of biology in the multifactorial biopsychosocial problem of LBP? This commentary considers whether biomechanics research has the potential to advance treatment of LBP, and how likely it is that this research will lead to better treatment strategies. A point-counterpoint format is taken to present both sides of the argument. First, the challenges faced by an approach that considers biomechanics in isolation are presented. Next, we describe 3 models that place substantial emphasis on biomechanical factors. Finally, reactions to each point are presented as a foundation for further research and clinical practice to progress understanding of the place for biomechanics in guiding treatment of LBP. J Orthop Sports Phys Ther 2019;49(6):425-436. Epub 15 May 2019. doi:10.2519/jospt.2019.8825.

Time to Reflect on the Role of Motor Control in Low Back Pain

The articles in this special issue on low back pain are the outcome of work undertaken by a series of working parties established during the meeting, "State-of-the-Art in Motor Control and Low Back Pain: International Clinical and Research Expert Forum," held in Chicago in October 2015. This multidisciplinary meeting provided an opportunity for discussion of key issues that interconnect motor control, pain, and the spine. What started as a relatively straightforward objective to summarize the field subsequently developed into an extensive process of literature review and discussion that culminated in the commentaries and articles presented in this special issue. We hope that the up-to-date information and in-depth insights into pain, motor control, and rehabilitation provide novel insights and a clear trajectory for future work and form the foundation for ongoing lively discussion. J Orthop Sports Phys Ther 2019;49(6):367-369. doi:10.2519/jospt.2019.0104.