Objective: Understanding the changes in muscle fiber typing is relevant in the context of muscle disorders because it
provides information on the metabolic profile and functional capacity. The aim of this study was to systematically review
the literature comparing muscle fiber typing in the back muscles of healthy subjects with low back pain (LBP) patients.
Methods: Predefined keywords regarding muscle fiber typing and back muscles were combined in PubMed and Web
of Science electronic search engines from inception to August 2014. Full-text articles were independently screened by
2 independent, blinded researchers. Full texts fulfilling the predefined inclusion criteria were assessed on risk of bias
by 2 independent researchers, and relative data were extracted. Data were not pooled because of heterogeneity in
biopsy locations and population.
Results: From the 214 articles that were identified, 18 met the inclusion criteria. These articles evaluated the muscle
fiber type distribution or proportional fiber type area between muscles, muscle layers, men, and women or healthy
subjects and LBP patients. Regarding muscle fiber type distribution, findings in healthy subjects and LBP patients
show no or inconclusive evidence for intermuscular and interindividual differentiation. Studies evaluating the
proportional fiber type area also suggest little intermuscular differentiation but provide plausible evidence that the
proportional area occupied by type I fibers is higher in women compared to men. The evidence for differentiation
based on the presence of low back pain is conflicting.
Conclusion: This study found that the evidence regarding muscle fiber typing in back muscles is either inconclusive
or shows little differences. The most plausible evidence exists for differentiation in proportional fiber type area
depending on sex. (J Manipulative Physiol Ther 2015;xx:1-11)
Key Indexing Terms: Paraspinal Muscles; Muscle Fibers; Skeletal; Low Back Pain
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Review of Fiber Typing in Lumbar Muscles
METHODS
This systematic review is reported following the
PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). 22
Qualification of Searchers/Raters
Research Question
The present systematic review aimed at answering
the following research question: What is known about
the muscle fiber type distribution or proportional area of
the back muscles (O) in healthy subjects (P) or LBP patients
(P) and are there intermuscular and interindividual
variations? In case of intermuscular variation, the control
condition (C) comprised another muscle, muscle layer, or
muscle region. To examine interindividual variation,
Cagnie et al
Review of Fiber Typing in Lumbar Muscles
1
1
1
1
1
1
1
0
1
1
1
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
1
1
0
1
1
1
1
0
1
1
1
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
1
1
1
1
0
0
1
0
0
0
3/6
2/6
1/6
3/6
3/6
4/6
3/6
0/6
2/6
3/6
2/6
2/6
2/6
B
B
B
B
B
B
B
B
B
B
B
B
B
1
1
1
1
1
1
1
1
1
1
0
0
0
0
0
1
1
1
1
1
0
0
0
0
0
1
1
1
1
1
4/6
4/6
4/6
4/6
4/6
B
B
B
B
B
the need for a third opinion. Based on the final total scores, 11
articles were of moderate quality, and 7 articles were of poor
quality. The most frequent risk of bias was formed by the
presence of selection bias and not accounting for confounders.
As the included studies had a case-control or cross-sectional
design, their results provided evidence at a B level.
Study Characteristics
RESULTS
Study Selection
A total of 214 hits were identified from the electronic
databases, and 8 additional articles were identified from
reviews' reference lists. After the 2 screening phases, 5
case-control and 13 cross-sectional articles fulfilled the
eligibility criteria and were included in this review (Fig 1).
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Review of Fiber Typing in Lumbar Muscles
Table 2. Table of Evidence of Selected Articles Concerning Fiber Type Distribution and Proportional Fiber Type Area
Control Group
Healthy subjects
Johnson et al25 6 cadavers, 17-30 y
10, 21-29 y
6 cadavers, 17-29 y
Jrgensen et al26
10, 21-29 y
Mannion et al27
Sirca and
Kostevc30
21 cadavers, 22-46 y
9 and 7, 20-30 y
Thorstensson
and Carlson31
Patient Group
Sample Site
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Review of Fiber Typing in Lumbar Muscles
Table 2. (continued)
Control Group
LBP patients
Bagnall et al23
Patient Group
12 and 7
undergoing IVD
surgery, 26-73 y
Ford et al24
18 patients
undergoing IVD
surgery, 28-73 y
Mannion et al18
29 and 30
chronic LBP
patients, mean
age 43.8 y
Regev et al29
4 and 11
undergoing
minimal
invasive fusion,
mean age 68 y
12 and 5
undergoing
IVD surgery,
28-50 y
Sirca and
Kostevc30
Sample Site
LO : 54% type I
LO : 70% type I
LO: 61% type I
Sig. larger area occupied by type
I fibers in compared to
No sig. differences between MF
and LO
MF and LO (L3)
Yoshihara et al33
22 and 7
undergoing
IVD surgery,
21-59 y
Yoshihara et al32
14 and 3
undergoing
IVD surgery,
21-54 y
13 and 6
undergoing
IVD surgery,
21-76 y
MF (L4/L5)
Zhao et al34
MF (L4/L5L5/S1)
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Review of Fiber Typing in Lumbar Muscles
Table 2. (continued)
Control Group
Patient Group
Crossman et al36
Mannion et al17
Sample Site
MF (L3/L4L4/L5)
(CON) or (L5/S1)
(PAT)
Mattila et al37
MF (L4/L5L5/S1)
Mazis et al38
MF (L4/L5)
A, affected; CON, control subjects; ES, erector spinae; IC, iliocostalis; IVD, intervertebral disc; LBP, low back pain; LO, longissimus; MF, multifidus;
NA, not affected; PAT, patients; SS, sacrospinalis.
Syntheses of Results
Fiber Type Distribution
Healthy Subjects. Back muscles of healthy subjects had a
fiber type I percentage ranging from 54% to 74.3%, type IIa from
16.4% to 30.2%, and type IIx from 4.6% to 22.34%. 26,27,30,35
In lumbar muscles only, these percentages varied from
54% to 70% for type I, 16.4% to 30.2% for type IIa, and
Screening
Identification
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Review of Fiber Typing in Lumbar Muscles
Included
Eligibility
Records screened
(n = 207)
Records excluded
(n = 169)
Studies included in
qualitative synthesis
(n = 18)
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Review of Fiber Typing in Lumbar Muscles
DISCUSSION
The aim of the present systematic literature study was to
summarize the literature with regard to the muscle fiber type
distribution and proportional fiber type area of back
muscles in healthy subjects and patients with LBP.
In both healthy subjects and LBP patients, there is
plausible evidence that there are no differences in fiber type
distribution and proportional area between distinct lumbar
muscles and between men and women. There is, however,
inconclusive evidence whether there is a difference in fiber
type distribution between lumbar vs thoracic and between
deep vs superficial muscle layers in healthy subjects only.
When comparing LBP patients and healthy subjects, the
evidence is conflicting. With respect to sex differences, there
is a discrepancy between the results of muscle fiber type
distribution and proportional area. It seems that the
distribution does not differ between men and women,
whereas 4 studies in this review suggest that the proportional
area occupied by type I fibers is larger in women compared to
men, both in healthy subjects and LBP patients. 17,18,27,31
Because the aforementioned conclusions were drawn
from a limited number of cross-sectional and case-control
studies, the strength of evidence is moderate to low, and
current evidence should be interpreted with caution. The
only exception seems to be the difference in proportional
fiber type area between men and women, as 4 studies
agreed on this. The larger proportional area occupied by
type I fibers in women possibly reflects their well-known
higher fatigue resistance. Mannion et al 39 demonstrated
with a trunk extension test that women are more resistant to
fatigue and that a higher fatigue resistance is accompanied
by a higher proportion of type I fibers (but not a higher
percentage of type I fibers). Based on this finding, we could
conclude that the described lower fatigue resistance in LBP
patients 40,41 would be manifested in a lower proportional
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Review of Fiber Typing in Lumbar Muscles
CONCLUSION
LIMITATIONS
Despite a high number of included studies, which should
be seen as strength of the current review, it appears that the
evidence regarding muscle fiber typing in back muscles is
either inconclusive or shows little differences. When
interpreting the results of the current review, some important
methodological limitations should be taken into account.
Studies included in this review are generally of low
methodological quality. This is inherent to case-control and
cross-sectional studies but is also due to the moderate to
high risk of bias identified in most of the studies. The
current review did not take into account the quality of
the studies to formulate the strength of evidence, but mainly
by adding up the studies and looking at the direction of
the effect.
In addition, the variety of biopsy locations (level,
muscle, depth, side) and subjects (cadavers, healthy
subjects, a wide range of patient groups) between studies
resulted in very few comparable studies. Consequently, a
meta-analysis enabling pooled statistics of effect is not
possible. Furthermore, there are a number of studies
conducted by the same research group, probably using the
same study population, which might affect the results as
well. 23 -26,32,33 Finally, this review is a summary of
observational studies which means that no inferences
CONTRIBUTORSHIP INFORMATION
Concept development (provided idea for the research):
B.C., F.D., L.D.
Design (planned the methods to generate the results):
B.C., F.D., L.D.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript):
B.C., L.D.
10
Cagnie et al
Review of Fiber Typing in Lumbar Muscles
Practical Applications
There is inconclusive evidence for intermuscular
and interindividual differentiation in lumbar
muscle fiber type distributions in healthy subjects
and LBP patients.
There is limited evidence that the proportional
fiber type area of MF and LO does not differ from
each other.
There is conflicting evidence about the proportional fiber type area between LBP patients and
healthy control subjects.
There is plausible evidence that the proportional
fiber type area occupied by type I fibers is higher
in women compared to men.
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