ACTIVATION OF LUMBAR SPINE STABILIZER MUSCLES IN PEOPLE WITH CHRONIC LOW BACK PAIN: A SYSTEMATIC REVIEW

ARAUJO, WILLIAM JOLLI DE; BASTOS, MATHEUS SIQUEIRA; BONVINO, MARCO AURÉLIO SERAFIM

doi:10.1590/S1808-185120222103257247

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REVIEW ARTICLE, BIOMECHANICS/REHABILITATION • Coluna/Columna 21 (3) • 2022 • https://doi.org/10.1590/S1808-185120222103257247 copy

ACTIVATION OF LUMBAR SPINE STABILIZER MUSCLES IN PEOPLE WITH CHRONIC LOW BACK PAIN: A SYSTEMATIC REVIEW

ATIVAÇÃO DOS MÚSCULOS ESTABILIZADORES DA COLUNA LOMBAR EM PESSOAS COM DOR LOMBAR CRÔNICA: UMA REVISÃO SISTEMÁTICA

ACTIVACIÓN DE LOS MÚSCULOS ESTABILIZADORES DE LA COLUMNA LUMBAR EN PERSONAS CON LUMBALGIA CRÓNICA: UNA REVISIÓN SISTEMÁTICA

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To compare the level of activation of the lumbar spine stabilizing muscles between people with chronic low back pain and healthy people.

Methods:

A systematic search was performed on May 10, 2021, of the following databases: PubMed, Physiotherapy Evidence Database and Cochrane Library. Inclusion and exclusion criteria were based on the PICO format. Two authors independently examined all articles that were selected for full reading. Disagreements were resolved through a discussion between the authors.

Results:

The bibliographical search identified 525 records, 165 of which were duplicates. After screening the titles, abstracts and the full text of the remaining 360 studies, 352 articles were excluded, and 8 articles were included in this review. The eight studies assessed the level of muscle activation in patients with chronic low back pain. In six studies patients with chronic low back pain had a higher activation level, in one study there was no statistically significant difference between groups,and in one study the activation level was lower in the chronic low back pain group.

Discussion:

This review was the first to review electromyography studies of the lumbar spine stabilizer muscles, covering all types of exposure procedures for evaluation. We believe that the recommendation of healthcare professionals for these patients to contract the stabilizer muscles are totally unnecessary.

Conclusion:

Patients with low back pain have a higher level of lumbar spine stabilizer muscle activation than healthy people. Level of evidence IIA; Systematic review of cohort studies.

Keywords:
Low Back Pain; Electromyography; Spine

Database	Keywords	Filters
PubMed	Back muscle OR Muscle activity OR muscle activation OR trunk muscles OR abdominal contraction OR spine stability OR Erector spinae AND Electromyography OR EMG AND Low back pain.	Only clinical trials
Physiotherapy Evidence Data base (PEDro)	Muscle* Electromyography* "Low back pain"	Only clinical trials
Cochrane Library	Part #1: Back muscle OR Muscle activity OR muscle activation OR trunk muscles OR spine stability.	Only clinical trials
	Part #2: Electromyography OR EMG.
	Part #3: Low Back Pain.
	Search: #Part 1 AND #Part 2 AND #Part 3.

Author/year	Participant characteristics
ERSHAD N. et al.⁷7 Ershad N, Kahrizi S, Abadi MF, Zadeh SF. Evaluation of trunk muscle activity in chronic low back pain patients and healthy individuals during holding loads. J Back Musculoskelet Rehabil. 2009;22(3):165-72. doi: 10.3233/BMR-2009-0230. https://doi.org/10.3233/BMR-2009-0230...	Groups	Sample	Age	Sex	Diagnosis
	Low back pain	10	24.7	10 women	Lumbar or lumbosacral pain with or without proximal radicular pain, current pain episode longer than 3 months.
	Healthy	10	25.4	10 women	With abdominal skinfold thickness < 25 mm.
LOMOND KV. et al.⁸8 Lomond KV, Jacobs JV, Hitt JR, DeSarno MJ, Bunn JY, Henry SM. Effects of low back pain stabilization or movement system impairment treatments on voluntary postural adjustments: a randomized controlled trial. Spine J. 2015;15(4):596-606. doi: 10.1016/j.spinee.2014.10.020. https://doi.org/10.1016/j.spinee.2014.10...	Low back pain	15	Not specified	Not specified	They had a history of chronic low back pain (≥ 12 months) with or without recurrences.
	Control	15	Not specified	Not specified	Absence of neurological, psychiatric, cardiovascular, or musculoskeletal disorders.
LIMA M et al.⁹9 Lima M, Ferreira AS, Reis FJJ, Paes V, Meziat-Filho N. Chronic low back pain and back muscle activity during functional tasks. Gait Posture. Vol. 61 n250-256. doi: 10.1016/j.gaitpost.2018.01.021. https://doi.org/10.1016/j.gaitpost.2018....	Chronic non-specific low back pain	40	35.2	33 men and 7 women	Experience low back pain for more than 3 months.
	Asymptomatic	40	35.9	29 men and 11 women	Never suffered important disability caused by low back pain.
KIM S, HYUN et al.¹⁰10 Kim SH, Kwon OY, Park KN, Kim MH. Comparison of erector spinae and hamstring muscle activities and lumbar motion during standing knee flexion in subjects with and without lumbar extension rotation syndrome. J ElectromyogrKinesiol. 2013;23(6):1311-6. doi: 10.1016/j.jelekin.2013.07.004. https://doi.org/10.1016/j.jelekin.2013.0...	Chronic low back pain	16	24.06	10 men and six women	Lumbar extension rotation syndrome for more than 7 weeks.
	Without chronic low back pain	14	23.79	8 men and 6 women	Without chronic low back pain.
FINNERAN M T. et al.¹¹11 Finneran MT, Mazanec D, Marsolais ME, Marsolais EB, Pease WS. Large-array surface electromyography in low back pain: a pilot study. Spine (Phila Pa 1976). 2003;28(13):1447-54. doi: 10.1097/01.BRS.0000067565.16832.B9. https://doi.org/10.1097/01.BRS.000006756...	Acute low back pain	13	41	7 men and 6 women	A current episode less than 6 weeks of duration.
	Chronic low back pain	25	47	12 men and 13 women	Chronic back pain.
	Control	163	34	51 men and 112 women	No current back pain and no back pain for the last 12 months.
BALASUBRAMANIAN V, JAYARAMAN S.¹²12 Balasubramanian V, Jayaraman S. Surface EMG based muscle activity analysis for aerobic cyclist. J Bodyw Mov Ther. 2009;13(1):34-42. doi: 10.1016/j.jbmt.2008.03.002. https://doi.org/10.1016/j.jbmt.2008.03.0...	Low back pain	7	26.58	7 men	History of low back pain for at least 1 year and no more than 3 years.
	Control	6	26.58	6 men	No history of low back pain for at least 1 year and up to 3 years.
LARIVIÈRE C, et al.¹³13 Larivière C, Gagnon D, Arsenault AB, Gravel D, Loisel P. Electromyographic activity imbalances between contralateral back muscles: An assessment of measurement properties. J Rehabil Res Dev. 2005;42(2):235-50. doi: 10.1682/jrrd.2004.01.0008. https://doi.org/10.1682/jrrd.2004.01.000...	Healthy	20	38	20 men	No back problems or physical disability presented.
	Unilateral low back pain	14	40	14 men	Lumbar or lumbosacral pain with or without proximal radicular pain (limiteddistally to the knees) and the presence of chronic pain, defined daily or almost daily pain for at least 3 months.
	Midline low back pain	21	38	21 men
HEALEY EL, et al.¹⁴14 Healey EL, Fowler NE, Burden AM, McEwan IM. The influence of different unloading positions upon stature recovery and paraspinal muscle activity. Clin Biomech (Bristol, Avon). 2005;20(4):365-71. doi: 10.1016/j.clinbiomech.2004.11.003. https://doi.org/10.1016/j.clinbiomech.20...	Chronic low back pain	11	33	Not specified	Suffered from low back pain for more than 6 months.
	Asymptomatic	11	30.5	Not specified	They were excluded if they had experienced back pain during the past year.

Author/year	Study objective	Muscles evaluated
ERSHAD N. et al.⁷7 Ershad N, Kahrizi S, Abadi MF, Zadeh SF. Evaluation of trunk muscle activity in chronic low back pain patients and healthy individuals during holding loads. J Back Musculoskelet Rehabil. 2009;22(3):165-72. doi: 10.3233/BMR-2009-0230. https://doi.org/10.3233/BMR-2009-0230...	The current study focused on the pattern of trunk muscle recruitment in patients with low back pain and subjects without low back pain during load bearing.	Rectus abdominis, external oblique, internal oblique, erector spinae, and multifidus muscles.
LOMOND KV et al.⁸8 Lomond KV, Jacobs JV, Hitt JR, DeSarno MJ, Bunn JY, Henry SM. Effects of low back pain stabilization or movement system impairment treatments on voluntary postural adjustments: a randomized controlled trial. Spine J. 2015;15(4):596-606. doi: 10.1016/j.spinee.2014.10.020. https://doi.org/10.1016/j.spinee.2014.10...	To measure self-rated disability, pain, range of muscle activation, and application of force during supported and unsupported leg raise tasks in people with and without low back pain.	Erector spinae, external oblique, internal oblique, and rectus abdominis muscle.
LIMA M. et al.⁹9 Lima M, Ferreira AS, Reis FJJ, Paes V, Meziat-Filho N. Chronic low back pain and back muscle activity during functional tasks. Gait Posture. Vol. 61 n250-256. doi: 10.1016/j.gaitpost.2018.01.021. https://doi.org/10.1016/j.gaitpost.2018....	Analyzed the activity of the back muscles during five functional tasks in patients with chronic lumbar painand compared it to asymptomatic controls.	Erector spinae and multifidus.
KIM S, HYUN, et al. ¹⁰10 Kim SH, Kwon OY, Park KN, Kim MH. Comparison of erector spinae and hamstring muscle activities and lumbar motion during standing knee flexion in subjects with and without lumbar extension rotation syndrome. J ElectromyogrKinesiol. 2013;23(6):1311-6. doi: 10.1016/j.jelekin.2013.07.004. https://doi.org/10.1016/j.jelekin.2013.0...	To compare the activity of the erector spinae muscles, and the amount and onset of lumbar movement during standing knee flexion among the subjects.	Erector spinae.
FINNERANMT. et al.¹¹11 Finneran MT, Mazanec D, Marsolais ME, Marsolais EB, Pease WS. Large-array surface electromyography in low back pain: a pilot study. Spine (Phila Pa 1976). 2003;28(13):1447-54. doi: 10.1097/01.BRS.0000067565.16832.B9. https://doi.org/10.1097/01.BRS.000006756...	To determine if the data differs by type of patient.	Multifidus,erector spinae, and quadratus lumborum.
BALASUBRAMANIAN V, JAYARAMAN S.¹²12 Balasubramanian V, Jayaraman S. Surface EMG based muscle activity analysis for aerobic cyclist. J Bodyw Mov Ther. 2009;13(1):34-42. doi: 10.1016/j.jbmt.2008.03.002. https://doi.org/10.1016/j.jbmt.2008.03.0...	To examine whether aerobic cyclingcauses any difference in muscle activity between the control and low back pain groups using electromyography.	Erector spinae.
LARIVIÈRE C. et al.¹³13 Larivière C, Gagnon D, Arsenault AB, Gravel D, Loisel P. Electromyographic activity imbalances between contralateral back muscles: An assessment of measurement properties. J Rehabil Res Dev. 2005;42(2):235-50. doi: 10.1682/jrrd.2004.01.0008. https://doi.org/10.1682/jrrd.2004.01.000...	Evaluated different measurement properties (influence of the control of asymmetrical forces and of the level of strength, the reliability, and sensitivityto the lumbar status) of the electromyography imbalance parameters.	Multifidus and erector spinae.
HEALEY EL. et al.¹⁴14 Healey EL, Fowler NE, Burden AM, McEwan IM. The influence of different unloading positions upon stature recovery and paraspinal muscle activity. Clin Biomech (Bristol, Avon). 2005;20(4):365-71. doi: 10.1016/j.clinbiomech.2004.11.003. https://doi.org/10.1016/j.clinbiomech.20...	To determine whether the paravertebral muscle activity of individuals with and without chronic low back pain can be altered by assuming different load bearing positions and if this has any impact after recovery of stature.	Erector spinae.

Author/year	Exposure procedures	Results
ERSHAD N. et al.⁷7 Ershad N, Kahrizi S, Abadi MF, Zadeh SF. Evaluation of trunk muscle activity in chronic low back pain patients and healthy individuals during holding loads. J Back Musculoskelet Rehabil. 2009;22(3):165-72. doi: 10.3233/BMR-2009-0230. https://doi.org/10.3233/BMR-2009-0230...	The subjectheld a box at three levels: 0 kg (holding a 370-g paper boxalmost considered as 0 kg), 6 kg, and 12 kg (holding a wooden box). The functional tasks were holding loads at two different trunk posture levels and three levels of external loads.	Activation of the internal oblique in patients with chronic low back pain is lower than in healthy individuals while bearing loads of 6 and 12 kg in the neutral trunk position. The chronic low back pain group had significantly greater external oblique muscle activation during the 12 kg loading on the flexed trunk than the control group. There were no significant differences in the activation of the erector spinae and multifidus muscles between patients with chronic low back pain and control groups.
LOMOND KV. et al.⁸8 Lomond KV, Jacobs JV, Hitt JR, DeSarno MJ, Bunn JY, Henry SM. Effects of low back pain stabilization or movement system impairment treatments on voluntary postural adjustments: a randomized controlled trial. Spine J. 2015;15(4):596-606. doi: 10.1016/j.spinee.2014.10.020. https://doi.org/10.1016/j.spinee.2014.10...	The individuals rested each foot on separate force plates while they were in dorsal decubitus and performed 4 repetitions of 2 voluntary movements of the left leg: a leg raise with support (SLR) and a leg raise without support (ULR).	During the MOVE phase, individuals with low back pain demonstrated greater muscle activation of the bilateral external oblique, erector spinae, internal oblique, and the rectus abdominis muscles than the individuals without pain.
LIMA M. et al.⁹9 Lima M, Ferreira AS, Reis FJJ, Paes V, Meziat-Filho N. Chronic low back pain and back muscle activity during functional tasks. Gait Posture. Vol. 61 n250-256. doi: 10.1016/j.gaitpost.2018.01.021. https://doi.org/10.1016/j.gaitpost.2018....	To perform five functional tasks: pick an object up off the floor, place an object on the floor, sit down, get up, and walk up the stairs. The tasks were repeated three times.	Greater electromyographic activity was observed in patients with chronic low back pain, except for the multifidus muscle during the task of picking a ball up off the ground.
KIM S. HYUN et al.¹⁰10 Kim SH, Kwon OY, Park KN, Kim MH. Comparison of erector spinae and hamstring muscle activities and lumbar motion during standing knee flexion in subjects with and without lumbar extension rotation syndrome. J ElectromyogrKinesiol. 2013;23(6):1311-6. doi: 10.1016/j.jelekin.2013.07.004. https://doi.org/10.1016/j.jelekin.2013.0...	The subject lifted the foot and flexed the knee at 90°. Then the subject was asked to maintain the knee flexion posture for 5seconds. The test was repeated 3 times.	Individuals with lumbar extension rotation syndrome had less electromyographicactivity of the contralateral erector spinae during standing knee flexion.
FINNERAN MT. et al.¹¹11 Finneran MT, Mazanec D, Marsolais ME, Marsolais EB, Pease WS. Large-array surface electromyography in low back pain: a pilot study. Spine (Phila Pa 1976). 2003;28(13):1447-54. doi: 10.1097/01.BRS.0000067565.16832.B9. https://doi.org/10.1097/01.BRS.000006756...	The flexion position required the participant to stand up with the feet shoulder-width apart with trunk flexion of 20°.Theweighted position required the participant to remain in a vertical position holding two 3-pound weights, one in each hand.	The control population demonstrated symmetrical lumbar muscle function, while those with back pain did not.
BALASUBRAMANIAN V, JAYARAMAN S.¹²12 Balasubramanian V, Jayaraman S. Surface EMG based muscle activity analysis for aerobic cyclist. J Bodyw Mov Ther. 2009;13(1):34-42. doi: 10.1016/j.jbmt.2008.03.002. https://doi.org/10.1016/j.jbmt.2008.03.0...	The subjects rode an aerobic bicycle and were instructed to maintain a comfortable posturewhile cycling at an average speed of 25-30 km/h for 30 minutes.	There was no statistical difference observed between the groups.
LARIVIÈRE C. et al.¹³13 Larivière C, Gagnon D, Arsenault AB, Gravel D, Loisel P. Electromyographic activity imbalances between contralateral back muscles: An assessment of measurement properties. J Rehabil Res Dev. 2005;42(2):235-50. doi: 10.1682/jrrd.2004.01.0008. https://doi.org/10.1682/jrrd.2004.01.000...	The subject performed static extension efforts using L5/S1 in real time with visual feedback.	Healthy individuals had lower absolute mean square root values than individuals with chronic low back pain.
HEALEY EL. et al. ¹⁴14 Healey EL, Fowler NE, Burden AM, McEwan IM. The influence of different unloading positions upon stature recovery and paraspinal muscle activity. Clin Biomech (Bristol, Avon). 2005;20(4):365-71. doi: 10.1016/j.clinbiomech.2004.11.003. https://doi.org/10.1016/j.clinbiomech.20...	Subjects walked at a self-selected rhythm on a treadmill for 20 minutes wearing a weighted vest (10% of body mass).	No significant difference was found between the right and left erector spinae muscle activity (normalized) in any group at the start or during recovery. The activity of the paraspinal muscle was greater in the chronic low back pain group at the beginning of the study and during all four recovery periods.

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[1] Correspondence: William Jolli de Araujo. Rua Ritinha Tavares, 100, Ap: 47 A, Vila Angélica, Sorocaba, S P, 18065425. william_jolli@hotmail.com