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22.09.2021 | Review Article

The flexion relaxation phenomenon in nonspecific chronic low back pain: prevalence, reproducibility and flexion–extension ratios. A systematic review and meta-analysis

verfasst von: Anaïs Gouteron, Anne Tabard-Fougère, Abderrahmane Bourredjem, Jean-Marie Casillas, Stéphane Armand, Stéphane Genevay

Erschienen in: European Spine Journal | Ausgabe 1/2022

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Abstract

Purpose

The flexion relaxation phenomenon (FRP) is characterized by the reduction of paraspinal muscle activity at maximum trunk flexion. The FRP is reported to be altered (persistence of spinal muscle activity) in nonspecific chronic low back pain (NSCLBP) and is considered a promising biomarker. The aim of this systematic review was to synthetize current knowledge on FRP in the NSCLBP population regarding prevalence, the reliability of FRP measurement using surface electromyography (sEMG), the average value, and variation of the relaxation ratios (RR).

Methods

Five databases were searched (PubMed, EMBASE, Web of Sciences, Cochrane Library, Pedro). A qualitative analysis was done for all included studies and meta-analysis studying prevalence, mean value of flexion relaxation ratio (FRR) and extension relaxation ratio (ERR), and difference between asymptomatic and NSCLBP FRR.

Results

Twenty-seven studies were included for qualitative analysis and 21 studies for meta-analysis. The prevalence of the altered FRP was 55% (95%CI [32–79%]) in the NSCLBP population. The studies on reliability reported good within-session and between-session reproducibility. In the NSLBP population, the mean FRR was 2.96 (95%CI [2.02; 3.90]) and the mean ERR was 4.07 (95%CI [2.08; 6.07]). The difference between asymptomatic and NSCLBP FRR was − 1.19 (95%CI [− 1.92, − 0.45]). In all meta-analysis, the I² index was > 80%.

Conclusion

An altered FRP is frequently found in NSCLBP population using sEMG and the test has a good reproducibility. The difference between asymptomatic and NSCLBP FRR was significant. Nevertheless, considering the high heterogeneity observed, additional research is required to confirm the value of RR.

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Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F et al (2006) Chapter 4 - European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 15:S192-300. https://doi.org/10.1007/s00586-006-1072-1CrossRefPubMedPubMedCentral

Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A et al (2016) Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388(10053):1545–1602. https://doi.org/10.1016/S0140-6736(16)31678-6CrossRef

Ahern DK, Follick MJ, Council JR, Laser-Wolston N, Litchman H (1988) Comparison of lumbar paravertebral EMG patterns in chronic low back pain patients and non-patient controls. Pain 34:153–160. https://doi.org/10.1016/0304-3959(88)90160-1CrossRefPubMed

Arena JG, Sherman RA, Bruno GM, Young TR (1989) Electromyographic recordings of 5 types of low back pain subjects and non-pain controls in different positions. Pain 37:57–65. https://doi.org/10.1016/0304-3959(89)90153-xCrossRefPubMed

Hubley-Kozey CL, Vezina MJ (2002) Differentiating temporal electromyographic waveforms between those with chronic low back pain and healthy controls. Clin Biomech (Bristol, Avon) 17:621–629. https://doi.org/10.1016/s0268-0033(02)00103-1CrossRef

Thomas JS, France CR (2008) The relationship between pain-related fear and lumbar flexion during natural recovery from low back pain. Eur Spine J 17(1):97–103. https://doi.org/10.1007/s00586-007-0532-6CrossRefPubMed

Floyd WF, Silver PH (1955) The function of the erectores spinae muscles in certain movements and postures in man. J Physiol 129:184–203. https://doi.org/10.1113/jphysiol.1955.sp005347CrossRefPubMedPubMedCentral

Andersson EA, Oddsson LI, Grundstrom H, Nilsson J, Thorstensson A (1996) EMG activities of the quadratus lumborum and erector spinae muscles during flexion-relaxation and other motor tasks. Clin Biomech (Bristol, Avon) 11(7):392–400. https://doi.org/10.1016/0268-0033(96)00033-2CrossRef

Kippers V, Parker AW (1984) Posture related to myoelectric silence of erectores spinae during trunk flexion. Spine 9(7):740–5. https://doi.org/10.1097/00007632-198410000-00015CrossRefPubMed

10.

Colloca CJ, Hinrichs RN (2005) The biomechanical and clinical significance of the lumbar erector spinae flexion-relaxation phenomenon: a review of literature. J Manipulative Physiol Ther 28:623–631. https://doi.org/10.1016/j.jmpt.2005.08.005CrossRefPubMed

11.

Gupta A (2001) Analyses of myo-electrical silence of erectors spinae. J Biomech 34(4):491–496. https://doi.org/10.1016/s0021-9290(00)00213-xCrossRefPubMed

12.

Mathiassen SE, Paquet V (2010) The ability of limited exposure sampling to detect effects of interventions that reduce the occurrence of pronounced trunk inclination. Appl Ergon 41:295–304. https://doi.org/10.1016/j.apergo.2009.08.006CrossRefPubMed

13.

Paquet N, Malouin F, Richards CL (1994) Hip-spine movement interaction and muscle activation patterns during sagittal trunk movements in low back pain patients. Spine 19:596–603. https://doi.org/10.1097/00007632-199403000-00016CrossRefPubMed

14.

Sihvonen T, Partanen J, Hanninen O, Soimakallio S (1991) Electric behavior of low back muscles during lumbar pelvic rhythm in low back pain patients and healthy controls. Arch Phys Med Rehabil 72:1080–1087PubMed

15.

Triano JJ, Schultz AB (1987) Correlation of objective measure of trunk motion and muscle function with low-back disability ratings. Spine 12:561–565. https://doi.org/10.1097/00007632-198707000-00010CrossRefPubMed

16.

Shirado O, Ito T, Kaneda K, Strax TE (1995) Flexion-relaxation phenomenon in the back muscles. a comparative study between healthy subjects and patients with chronic low back pain. Am J Phys Med Rehabil 74:139–144PubMed

17.

Alschuler KN, Neblett R, Wiggert E, Haig AJ, Geisser ME (2009) Flexion-relaxation and clinical features associated with chronic low back pain: a comparison of different methods of quantifying flexion-relaxation. Clin J Pain 25:760–766. https://doi.org/10.1097/AJP.0b013e3181b56db6CrossRefPubMed

18.

Page I, Marchand AA, Nougarou F, O’Shaughnessy J, Descarreaux M (2015) Neuromechanical responses after biofeedback training in participants with chronic low back pain: an experimental cohort study. J Manipulative Physiol Ther 38:449–457. https://doi.org/10.1016/j.jmpt.2015.08.005CrossRefPubMed

19.

Schinkel-Ivy A, Nairn BC, Drake JD (2013) Evaluation of methods for the quantification of the flexion-relaxation phenomenon in the lumbar erector spinae muscles. J Manipulative Physiol Ther 36:349–358. https://doi.org/10.1016/j.jmpt.2013.05.017CrossRefPubMed

20.

Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Annals of Internal Med 151(264–9):W64. https://doi.org/10.7326/0003-4819-151-4-200908180-00135CrossRef

21.

Downs SH, Black N (1998) The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 52(6):377–384. https://doi.org/10.1136/jech.52.6.377CrossRefPubMedPubMedCentral

22.

Azadinia F, Ebrahimi ET, Kamyab M, Parnianpour M, Cholewicki J, Maroufi N (2017) Can lumbosacral orthoses cause trunk muscle weakness? A systematic review of literature. Spine J 17:589–602. https://doi.org/10.1016/j.spinee.2016.12.005CrossRefPubMed

23.

Abboud J, Lardon A, Boivin F, Dugas C, Descarreaux M (2016) Effects of muscle fatigue, creep, and musculoskeletal pain on neuromuscular responses to unexpected perturbation of the trunk: a systematic review. Front Hum Neurosci 10:667. https://doi.org/10.3389/fnhum.2016.00667CrossRefPubMed

24.

Dhouib A, Tabard-Fougere A, Hanquinet S, Dayer R (2018) Diagnostic accuracy of MR imaging for direct visualization of lumbar pars defect in children and young adults: a systematic review and meta-analysis. Eur Spine J 27:1058–1066. https://doi.org/10.1007/s00586-017-5305-2CrossRefPubMed

25.

Viechtbauer W (2010) Conducting meta-analyses in r with the metafor package. J Stat Soft 36:1–48CrossRef

26.

Viechtbauer W (2005) Bias and efficiency of meta-analytic variance estimators in the random-effects model. J Edu Behav Stat 30:261–293. https://doi.org/10.3102/10769986030003261CrossRef

27.

Lewis S, Clarke M (2001) Forest plots: trying to see the wood and the trees. BMJ 322:1479–1480. https://doi.org/10.1136/bmj.322.7300.1479CrossRefPubMedPubMedCentral

28.

Sipahi I, Akay MH, Dagdelen S, Blitz A, Alhan C (2014) Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease : meta-analysis of randomized clinical trials of the arterial grafting and stenting ERA. JAMA Intern Med 174:223–230. https://doi.org/10.1001/jamainternmed.2013.12844CrossRefPubMed

29.

Laird RA, Keating JL, Ussing K, Li P, Kent P (2019) Does movement matter in people with back pain? Investigating ‘atypical’ lumbo-pelvic kinematics in people with and without back pain using wireless movement sensors. BMC Musculoskelet Disord 20:28. https://doi.org/10.1186/s12891-018-2387-xCrossRefPubMedPubMedCentral

30.

Lalanne K, Lafond D, Descarreaux M (2009) Modulation of the flexion-relaxation response by spinal manipulative therapy: a control group study. J Manipulative Physiol Ther 32:203–209. https://doi.org/10.1016/j.jmpt.2009.02.010CrossRefPubMed

31.

Mannion AF, Taimela S, Muntener M, Dvorak J (2001) Active therapy for chronic low back pain part 1. Effects on back muscle activation, fatigability, and strength. Spine 26:897–908. https://doi.org/10.1097/00007632-200104150-00013CrossRefPubMed

32.

Marshall PW, Murphy BA (2008) Muscle activation changes after exercise rehabilitation for chronic low back pain. Arch Phys Med Rehabil 89:1305–1313. https://doi.org/10.1016/j.apmr.2007.11.051CrossRefPubMed

33.

Marshall PW, Murphy BA (2006) Evaluation of functional and neuromuscular changes after exercise rehabilitation for low back pain using a Swiss ball: a pilot study. J Manipulative Physiol Ther 29:550–560. https://doi.org/10.1016/j.jmpt.2006.06.025CrossRefPubMed

34.

Marshall P, Murphy B (2006) The relationship between active and neural measures in patients with nonspecific low back pain. Spine 31:E518-24. https://doi.org/10.1097/01.brs.0000224351.97422.7cCrossRefPubMed

35.

Marshall P, Murphy B (2006) Changes in the flexion relaxation response following an exercise intervention. Spine 31:E877–E883. https://doi.org/10.1097/01.brs.0000244557.56735.05CrossRefPubMed

36.

Masse-Alarie H, Beaulieu LD, Preuss R, Schneider C (2017) Repetitive peripheral magnetic neurostimulation of multifidus muscles combined with motor training influences spine motor control and chronic low back pain. Clin Neurophysiol 128:442–453. https://doi.org/10.1016/j.clinph.2016.12.020CrossRefPubMed

37.

McGorry RW, Lin JH (2012) Flexion relaxation and its relation to pain and function over the duration of a back pain episode. PLoS ONE 7:e39207. https://doi.org/10.1371/journal.pone.0039207CrossRefPubMedPubMedCentral

38.

Moore A, Mannion J, Moran RW (2015) The efficacy of surface electromyographic biofeedback assisted stretching for the treatment of chronic low back pain: a case-series. J Bodyw Mov Ther 19:8–16. https://doi.org/10.1016/j.jbmt.2013.12.008CrossRefPubMed

39.

Ringheim I, Austein H, Indahl A, Roeleveld K (2015) Postural strategy and trunk muscle activation during prolonged standing in chronic low back pain patients. Gait Posture 42:584–589. https://doi.org/10.1016/j.gaitpost.2015.09.008CrossRefPubMed

40.

Ritvanen T, Zaproudina N, Nissen M, Leinonen V, Hanninen O (2007) Dynamic surface electromyographic responses in chronic low back pain treated by traditional bone setting and conventional physical therapy. J Manipulative Physiol Ther 30:31–37. https://doi.org/10.1016/j.jmpt.2006.11.010CrossRefPubMed

41.

Watson PJ, Kerry Booker C, Main CJ (1997) Evidence for the role of psychological factors in abnormal paraspinal activity in patients with chronic low back pain. J Musculoskeletal Pain 5:41–56. https://doi.org/10.1300/J094v05n04_05CrossRef

42.

Watson PJ, Booker CK, Main CJ, Chen AC (1997) Surface electromyography in the identification of chronic low back pain patients: the development of the flexion relaxation ratio. Clin Biomech (Bristol, Avon) 12:165–171. https://doi.org/10.1016/s0268-0033(97)00065-xCrossRef

43.

Xia T, Long CR, Vining RD, Gudavalli MR, DeVocht JW, Kawchuk GN et al (2017) Association of lumbar spine stiffness and flexion-relaxation phenomenon with patient-reported outcomes in adults with chronic low back pain - a single-arm clinical trial investigating the effects of thrust spinal manipulation. BMC Complement Altern Med 17:303. https://doi.org/10.1186/s12906-017-1821-1CrossRefPubMedPubMedCentral

44.

Rose-Dulcina K, Genevay S, Dominguez D, Armand S, Vuillerme N (2019) Flexion-relaxation ratio asymmetry and its relation with trunk lateral rom in individuals with and without chronic non-specific low back pain. Spine 45(1):E1–E9. https://doi.org/10.1097/BRS.0000000000003196CrossRef

45.

Murillo C, Martinez-Valdes E, Heneghan NR, Liew B, Rushton A, Sanderson A, Fallah D (2019) High-density electromyography provides new insights into the flexion relaxation phenomenon in individuals with low back pain. Sci Rep 9(1):15938. https://doi.org/10.1038/s41598-019-52434-9CrossRefPubMedPubMedCentral

46.

Arguisuelas MD, Lisón JF, Doménech-Fernández J, Martínez-Hurtado I, Salvador Coloma P, Sánchez-Zuriaga D (2019) Effects of myofascial release in erector spinae myoelectric activity and lumbar spine kinematics in non-specific chronic low back pain: randomized controlled trial. Clin Biomech (Bristol, Avon) 63:27–33. https://doi.org/10.1016/j.clinbiomech.2019.02.009CrossRef

47.

Bicalho E, Setti JA, Macagnan J, Cano JL, Manffra EF (2010) Immediate effects of a high-velocity spine manipulation in paraspinal muscles activity of nonspecific chronic low-back pain subjects. Man Ther 15:469–475. https://doi.org/10.1016/j.math.2010.03.012CrossRefPubMed

48.

Dubois JD, Piche M, Cantin V, Descarreaux M (2011) Effect of experimental low back pain on neuromuscular control of the trunk in healthy volunteers and patients with chronic low back pain. J Electromyogr Kinesiol 21:774–781. https://doi.org/10.1016/j.jelekin.2011.05.004CrossRefPubMed

49.

Fehrmann E, Tuechler K, Kienbacher T, Mair P, Spreitzer J, Fischer L et al (2017) Comparisons in muscle function and training rehabilitation outcomes between avoidance-endurance model subgroups. Clin J Pain 33:912–920. https://doi.org/10.1097/ajp.0000000000000479CrossRefPubMed

50.

Geisser ME, Haig AJ, Wallbom AS, Wiggert EA (2004) Pain-related fear, lumbar flexion, and dynamic EMG among persons with chronic musculoskeletal low back pain. Clin J Pain 20:61–69. https://doi.org/10.1097/00002508-200403000-00001CrossRefPubMed

51.

Kim JH, Kim YE, Bae SH, Kim KY (2013) The effect of the neurac sling exercise on postural balance adjustment and muscular response patterns in chronic low back pain patients. J Phys Ther Sci 25:1015–1019. https://doi.org/10.1589/jpts.25.1015CrossRefPubMedPubMedCentral

52.

Laird RA, Keating JL, Kent P (2018) Subgroups of lumbo-pelvic flexion kinematics are present in people with and without persistent low back pain. BMC Musculoskelet Disord 19:309. https://doi.org/10.1186/s12891-018-2233-1CrossRefPubMedPubMedCentral

53.

Fairbank JCT, Pynsent PB (2000) The oswestry disability index. Spine 25:2940–2953. https://doi.org/10.1097/00007632-200011150-00017CrossRefPubMed

54.

Horn ME, Bishop MD (2013) Flexion relaxation ratio not responsive to acutely induced low back pain from a delayed onset muscle soreness protocol. ISRN Pain 2013:617698. https://doi.org/10.1155/2013/617698CrossRefPubMedPubMedCentral

55.

Hodges PW, Danneels L (2019) Changes in structure and function of the back muscles in low back pain: Different time points, observations, and mechanisms. J Orthop Sports Phys Ther 49:464–476. https://doi.org/10.2519/jospt.2019.8827CrossRefPubMed

56.

Schinkel-Ivy A, Nairn BC, Drake JD (2014) Quantification of the lumbar flexion-relaxation phenomenon: comparing outcomes of lumbar erector spinae and superficial lumbar multifidus in standing full trunk flexion and slumped sitting postures. J Manipulative Physiol Ther 37:494–501. https://doi.org/10.1016/j.jmpt.2014.07.003CrossRefPubMed

57.

Jin SG, Ning XP, Mirka GA (2012) An algorithm for defining the onset and cessation of the flexion-relaxation phenomenon in the low back musculature. J Electromyogr Kinesiol 22:376–382. https://doi.org/10.1016/j.jelekin.2012.01.003CrossRefPubMed

58.

Czaprowski D, Kolwicz A, Afeltowicz A, Pawlowska P, Oleksy L (2015) Reliability of measurements of the extension-flexion ratio with surface EMG. J Back Musculoskelet Rehabil 28:827–832. https://doi.org/10.3233/bmr-150590CrossRefPubMed

59.

Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G (2000) Development of recommendations for SEMG sensors and sensor placement procedures. J Electromyogr Kinesiol 10:361–374. https://doi.org/10.1016/S1050-6411(00)00027-4CrossRefPubMed

Titel: The flexion relaxation phenomenon in nonspecific chronic low back pain: prevalence, reproducibility and flexion–extension ratios. A systematic review and meta-analysis
verfasst von: Anaïs Gouteron
Anne Tabard-Fougère
Abderrahmane Bourredjem
Jean-Marie Casillas
Stéphane Armand
Stéphane Genevay
Publikationsdatum: 22.09.2021
Verlag: Springer Berlin Heidelberg
Erschienen in: European Spine Journal / Ausgabe 1/2022
Print ISSN: 0940-6719
Elektronische ISSN: 1432-0932
DOI: https://doi.org/10.1007/s00586-021-06992-0

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The flexion relaxation phenomenon in nonspecific chronic low back pain: prevalence, reproducibility and flexion–extension ratios. A systematic review and meta-analysis