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FIBER TYPING OF THE ERECTOR SPINAE AND

MULTIFIDUS MUSCLES IN HEALTHY CONTROLS


AND BACK PAIN PATIENTS: A SYSTEMATIC
LITERATURE REVIEW
Barbara Cagnie, PT, PhD, a Famke Dhooge, PT, b Charline Schumacher, PT, b

Kayleigh De Meulemeester, PT, b Mirko Petrovic, MD, c


Jessica van Oosterwijck, PT, PhD, d and Lieven Danneels, PT, PhD e
ABSTRACT

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

Assistant Professor, Department of Rehabilitation Sciences


and Physiotherapy, Ghent University, Ghent, Belgium.
b
Research Fellow, Department of Rehabilitation Sciences and
Physiotherapy, Ghent University, Ghent, Belgium.
c
Full Professor, Ghent University Hospital, Department of
Geriatrics, Ghent, Belgium.
d
Postdoctoral Research Fellow, Department of Rehabilitation
Sciences and Physiotherapy, Ghent University, Ghent, Belgium.
e
Full Professor, Department of Rehabilitation Sciences and
Physiotherapy, Ghent University, Ghent, Belgium.
Submit requests for reprints to: Barbara Cagnie, PT, PhD, De
Pintelaan 185 3B3, 9000 Ghent, Belgium.
(e-mail: Barbara.cagnie@ugent.be).
Paper submitted April 3, 2015; in revised form September 1,
2015; accepted September 18, 2015.
0161-4754
Copyright 2015 by National University of Health Sciences.
All rights reserved.
http://dx.doi.org/10.1016/j.jmpt.2015.10.004

uscle fiber typing plays a determining role in the


functional capacity of a muscle. Although muscles responsible for movement and acceleration
benefit from rapid and short contracting fibers, postural
muscles are preferably endowed with fatigue-resistant
fibers. 1 Consequently, one might suggest that the back
muscles would predominantly consist of type I fibers, as
these fibers are particularly suitable to maintain the
long-lasting contractions that are essential for the human
upright position. 2 However, besides ensuring the upright
position, the back muscles also have an important
movement function. To meet these dynamic stability
demands, different back muscles play different roles. 3,4
Bergmark 5 introduced a concept of 2 muscular systems: the
global and the local system. The global muscles span
multiple spinal segments which enables them to produce
torque and to provide general trunk stabilization without
direct influence on the spinal segments. Because of their
morphology, the thoracic erector spinae (ES) are considered

Cagnie et al
Review of Fiber Typing in Lumbar Muscles

as global muscles. The local muscles are attached directly to


the lumbar vertebrae and provide segmental stability.
Traditionally, the lumbar ES and multifidus (MF) are
classified as local muscles. 6,7 The functional differentiation
between these muscles and sometimes also between
superficial and deep muscle layers 8 -10 is suggested to be
reflected in differentiated fiber typing. 11,12
Besides intermuscular fiber type differentiation, interindividual variation is suggested as well. The best-known
example is the difference in fiber type distribution of the
metabolically active muscles of sprinters and endurance
athletes. 13,14 In addition to activity-related differences,
muscle fiber typing may also differ depending on sex, 15
age, 16 and health status. In patients with low back pain
(LBP), alterations in fiber typing in MF and ES are assumed
to be possible factors in the etiology and/or recurrence of
pain symptoms as it negatively affects muscle strength and
endurance. 17 Nevertheless, it is unclear whether inadequate
fiber type characterizations render these patients more
prone to develop symptoms or whether changes in fiber
typing occur as a consequence of pain or pathology. 17,18 In
case of the latter, type I fibers have been argued to be more
affected by pain and immobilization than type II fibers. 19
According to literature, this is merely reflected in an
alteration in fiber size, 1 rather than an alteration in fiber
type distribution. 17,18,20,21 Therefore, it is not only
interesting to investigate muscle fiber type percentages
but also the proportional area occupied per fiber type (in
percentages, determined by the size and relative distribution
of the fiber types) in patients with LBP compared with
healthy controls.
The purpose of this study was to systematically review
the literature comparing muscle fiber typing in the back
muscles of healthy subjects with LBP patients. The review
combines these results systematically to summarize muscle
fiber type distribution and proportional area occupied per
fiber type in healthy subjects and patients with LBP.

METHODS
This systematic review is reported following the
PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). 22

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comparison (C) was made between sexes or between LBP


patients and healthy controls.

Information Sources and Search Strategy


Relevant studies were identified by searching the
electronic databases PubMed and Web of Science from
inception to August 2014. The search strategy was based on
a combination of the following Mesh terms or free-text
words, derived from the PICOS approach: (Back muscles
[MESH] OR Spine [MESH] OR Back [MESH] OR
erector spinae OR multifidus OR Spinal Diseases
[MESH] OR Back Pain [MESH]) AND (Muscle Fibers,
Skeletal [MESH] OR Myosin Heavy Chains [MESH]
OR fiber size OR fibre size OR fiber area OR fibre
area OR fiber characteristics OR fibre characteristics
OR fiber distribution). [MESH] was left out in the Web
of Science search. In PubMed, an additional filter for
Humans was set. Furthermore, reference lists of retrieved
review articles were scanned.

Eligibility Criteria and Study Selection


To be included in the systematic review, each study had
to meet the following review specific inclusion criteria:
All study subjects were adult (ie, N 18 years)
Studies described muscle fiber typing (distribution or
proportional area) in back muscles of healthy subjects
and/or LBP patients
Case-control and cross-sectional studies
Studies in English, French, Dutch, or German.
Exclusion criteria included LBP patients with scoliosis
or a neurologic, systemic, or muscle disease; review
articles; abstracts; letters to the editor; and case reports.
No limitations were made based on year of publication.
Title and abstract of all search results were screened to
examine whether they complied with the inclusion criteria.
Full texts of the remaining potentially interesting articles
were retrieved, and the full content of the articles was
screened to ensure fulfillment of the inclusion criteria.

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,

All identified titles and abstracts were independently


screened for inclusion by FD (MSc in rehabilitation
sciences and physiotherapy, PhD candidate). She was
trained by the first author (BC), who obtained a PhD and
has previously published several systematic review. Fulltext articles were then independently screened by 2
independent, blinded researchers: FD and CS (MSc in
rehabilitation sciences and physiotherapy). Methodological
quality of each individual article was then assessed by the
same 2 raters.

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Data Items and Collection


Relevant information from each included article was
extracted and structurally presented in Table 1, containing
following items: authors, subject characteristics (age, sex,
and diagnosis), biopsy location, and results (fiber type
distribution and proportional area).

Risk of Bias in Individual Studies


As all studies were observational studies (case-control or
cross-sectional design), risk of bias was assessed by 2
independent, blinded researchers (FD and CS) using the
case-control study checklist from the EBRO platform,
provided by the Dutch Cochrane Centre. The 6 items that
were assessed were related to (1) descriptions of the patient
group, (2) description of the control group, (3) selection bias,
(4) exposure, (5) blinded measurement of exposure, and (6)
confounders. Per item, 1 point was allocated for a fulfilled
item and 0 points in case of absent or insufficient information.
In all cross-sectional studies, items 2 and 5 were scored 0.
Results of both raters were compared, and differences were
discussed in a consensus meeting, which led to a final score
on the related item (Table 2). A total score was obtained for
each study by adding up the item scores. The study quality
was defined as poor (0-2/6), moderate (3-4/6), or good (5-6/
6). Depending on methodological quality, a level of evidence
was determined according to the 2005 classification system
of the Dutch Institute for Healthcare Improvement. As we only
included case-control and cross-sectional studies, each study
was classified with a level of evidence B. Finally, strength of
conclusion was calculated for each outcome parameter and
was placed between brackets when describing the results. A
strength of conclusion 2 (plausible evidence) is given when
there are at least 2 independently conducted studies of level B,
whereas a strength of conclusion 3 (limited evidence) is given
when there is at least 1 study of level B. Strength of conclusion
I (inconclusive or conflicting evidence) is given in case of
inconsistent or inconclusive studies of any level.

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Review of Fiber Typing in Lumbar Muscles

Table 1. Methodological Quality and Levels of Evidence of the


Included Studies
Level of
1 2 3 4 5 6 Total Evidence
Cross-sectional design
Bagnall et al23
Ford et al24
Johnson et al25
Jrgensen et al26
Mannion et al27
Mannion et al18
Rantanen et al28
Regev et al29
Sirca and Kostevc30
Thorstensson and Carlson31
Yoshihara et al32
Yoshihara et al33
Zhao et al34
Case-control design
Bajek et al35
Crossman et al36
Mannion et al17
Mattila et al37
Mazis et al38

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

1. Patients group clearly and adequately defined?


2. Control group clearly and adequately defined?
3. Selection bias can sufficiently be excluded?
4. Exposure is clearly defined and method for exposure assessment
adequate?
5. Exposure blind to the disease status?
6. Important confounders identified and taken into account?
Scoring: 1 = sufficient information; 0 = absent or insufficient information.

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).

Risk of Bias and Level of Evidence


The methodological quality and levels of evidence of the
different studies are reported in Table 1. Initially, the 2 raters
agreed in 86.6% of the cases (71/82 items). During a consensus
meeting, the remaining 11 items were discussed between the 2
raters, and consensus was reached for all disagreements without

The number of subjects studied varied between 15 and


117. Three articles investigated only men. 25,26,36 Nine
articles compared men and women, 17,18,23,27,28,31,35,37,38
and 6 articles pooled men and women. 24,29,30,32-34 Five
articles included only healthy subjects, 25 -28,31 7 studied
only LBP patients, 18,23, 24,29,32 -34 and 6 studied
both. 17,30,35-38 Only 2 articles took thoracic biopsy samples
besides lumbar samples. 27,30 Biopsy samples from
healthy subjects were harvested from cadavers in 6
articles. 26,28,30,35,37,38 The samples from LBP patients
were obtained from patients undergoing intervertebral
disk (IVD) surgery in 10 studies 23,24,29,30,32-35,37,38 and
from patients undergoing surgery for different severe LBP
conditions in 1 study, 17 whereas in 2 articles, they were
obtained from recurrent and chronic LBP patients, not
undergoing surgery 18,36 (Table 2).

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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

17, mean age 23.0 y


14, mean age 29.4 y

Rantanen et al28 14 and 7 cadavers,


23-65 y

Sirca and
Kostevc30

21 cadavers, 22-46 y

9 and 7, 20-30 y
Thorstensson
and Carlson31

Patient Group

Sample Site

Fiber Type Distribution (%)

Super MF: 58.4% type I


Deep MF: 54.9% type I
MF, LO and IC (L3) MF: 54% type I, 22% type IIa,
MF and LO (L3)
24% type IIx
LO: 70% type I, 18.4% type IIa,
11.1% type IIx
IC: 55% type I, 19.4% type IIa,
25.6% type IIx
Sig. more type I fibers in LO
compared to MF and IC
Sig. more type IIx fibers in MF
and IC compared to LO
No sig. differences for type IIa
fibers
MF 57%-61.7% type I,
23.7%-29.9% type IIa,
13%-14.6% type IIx
LO 62.6%-64.9% type I,
24.2%-30.2% type IIa,
7.2%-10.8% type IIx
Sig. more type I fibers in LO
(63.8%) compared to MF (59.4%)
No sig. differences for type IIa and
IIx fibers between MF and LO
ES (T10 and L3)
T10: 62% type I, 26.8% type
IIa, 10.9% type IIx
L3: 65% type I, 24.2% type
IIa, 9.6% type IIx
T10: 67.8% type I, 27.3%
type IIa, 4.6% type IIx
L3: 63.6% type I, 26.9% type
IIa, 9% type IIx
No sig. sex differences
No sig. region differences

Proportional Fiber Type Area (%)

Super and deep MF

Super and deep MF


and IC (L4/L5) and
deep MF (L3/L4 and
L5/S1)

MF: 63% type I, 18.1%-25.5%


type IIa, 14.2%-16.1% type IIx
LO: 71% type I, 17%-21.7%
type IIa, 4.8%-23.7% type IIx
IC: 58% type I, 20.1%-22% type
IIa, 17.3%-23.7% type IIx
MF: 63% type I, 23.7%-30.4%
type IIa, 10.5%-13.1% type IIx
LO: 65% type I, 26.7%-32.4%
type IIa, 5.7%-8.8% type IIx

T10: 61.9% type I, 27.7%


type IIa, 10.1% type IIx
L3: 66.4% type I, 23.9% type
IIa, 8.8% type IIx
T10: 76% type I, 21% type IIa,
2.8% type IIx
L3: 72.8% type I, 20.7% type
IIa, 6.2% type IIx
Sig. larger area occupied by type
I fibers in compared to
Sig. larger area occupied by type
IIa/IIx fibers in compared to
Sig. larger area occupied by type IIx
fibers at L3 compared to T10 in
Sig. larger area occupied by type IIx
fibers at T10 compared to L3 in

On average 62.6% type I fibers


in paraspinal muscles
: 61.5% type I fibers
: 68.5% type I fibers
No sig. muscle differences
No sig. sex differences
MF and LO (T9 and T9 Super MF + LO: 74.3% type
L3)
I, 18.19% type IIa, 6.51% type IIx
T9 Deep MF + LO: 73.16% type
I, 17.45% type IIa, 8.97% type IIx
L3 Super MF + LO: 56.96% type
I, 20.7% type IIa, 22.34% type IIx
L3 Deep MF + LO: 63.21% type
I, 25.87% type IIa, 10.6% type IIx
Sig. more type I fibers in deep
MF + LO at T8 compared to L3
Sig. more type I fibers in deep
MF + LO at L3 compared to
Super MF + LO
MF and LO (L3)
MF : 60% type I, 23% type MF : 58% type I
IIa, 17% type IIx
MF : 75% type I
MF : 62% type I, 17% type MF: 65% type I

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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

Proportional Fiber Type Area (%)

IIa, 21% type IIx


MF: 62% type I, 20% type IIa,
18% type IIx
LO : 56% type I, 22% type
IIa, 22% type IIx
LO : 58% type I, 21% type
IIa, 20% type IIx
LO: 57% type I, 22% type IIa,
2% type IIx
No sig. sex differences
No sig. differences between
MF and LO

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

Left super MF: 60% type


Iright super MF 48% type I
Left deep MF: 41% type
Iright deep MF 53% type I
Left super MF: 65% type
Iright super MF 54% type I
Left deep MF: 58% type
Iright deep MF 58% type I
No sig. sex differences
SS and MF (L5)
SS A side: 59% type ISS NA
side: 53% type I
MF A side: 53% type IMF
NA side: 49% type I
No sig. muscle differences
No sig. side differences
ES (LO and IC) (L3/ : 65.4% type I, 18.1% type
L4)
IIa, 15.4% type IIx
: 73.0% type I, 16.1% type
IIa, 10.4% type IIx
Sig. more type I fibers in
compared to
Sig. more type IIx fibers in
compared to
MF and IC (no levels 63.3% type I, 18.5% type IIa,
determined)
18.2% type IIx
No sig. muscle (layer) differences,
therefore results were pooled
SS and MF (L5)

MF and LO (L3)

Yoshihara et al33

22 and 7
undergoing
IVD surgery,
21-59 y

MF (L4 and L5)

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

Fiber Type Distribution (%)

MF (L4/L5L5/S1)

: 69.7% type I, 15.7% type IIa,


13.5% type IIx
: 80.3% type I, 11.8% type IIa,
7.5% type IIx
Sig. larger area occupied by type
I fibers in compared to
Sig. larger area occupied by type
IIx fibers in compared to

Super MF + LO: 56.38% type I,


25.84% type IIa, 16.92% type IIx
Deep MF + LO: 63.02% type I,
24.19% type IIa, 12.5% type IIx
Sig. more type I fibers in deep
MF + LO compared to super
MF + LO
L4 A: 65.7% type IL4 NA:
63.9% type I
L5 A: 66% type I fibersL5
NA: 60.6% type I
Sig. more type I fibers on the A
compared to the NA at L5
A: 66% type INA: 61% type I
Sig. more type I fibers on the A
compared to the NA
A: 60.2% type INA: 58.1% type
I
No sig. side differences
(continued on next page)

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Table 2. (continued)
Control Group

Patient Group

LBP patients vs healthy controls


35 and 6 cadavers, 46 and 30
Bajek et al35
17-50 y
undergoing
IVD surgery,
27-67 y

Crossman et al36

Mannion et al17

Sample Site

Fiber Type Distribution (%)

PAT : 67.4% type I, 18.16%


type IIa, 14.23% type IIx
PAT : 66.4% type I, 18.81%
type IIa, 14.79% type IIx
CON : 60.76% type I, 21.72%
type IIa, 17.48% type IIx
CON : 65.98% type I, 16.4%
type IIa, 17.62% type IIx
Sig. more type IIa fibers in
compared to CON
Sig. more type I in PAT
compared to CON
Sig. more type IIa/IIx in CON
compared to PAT
No sig. differences in CON
compared to PAT
No sig. differences in
compared to PAT
32
32 chronic
ES (L3)
PAT: 64% type I
LBP patients,
CON: 64% type I
18-55 y
No sig. differences between
PAT and CON
12, mean age 22.9 y 12 and 9 , ES (L3) (CON)MF PAT : 51% type I, 24% type
9, mean age 33.3 y undergoing
(L3 or L4) (PAT)
IIa, 23.4% type IIx
surgery for
PAT : 50.1% type I, 17.3%
severe LBP,
type IIa, 30.6% type IIx
mean age 22.1
CON : 66.1% type I, 24.4%
() to 35.9 () y
type IIa, 7.9% type IIx
CON : 66.5% type I, 24.6%
type IIa, 8.2% type IIx
Sig. more type I fibers in CON
compared to PAT
Sig. more type IIx fibers in
PAT compared to CON
No sig. differences in
compared to

Proportional Fiber Type Area (%)

MF (L3/L4L4/L5)
(CON) or (L5/S1)
(PAT)

Mattila et al37

9 and 3 cadavers, 22 and 19


21-58 y
undergoing IVD
surgery, mean
age 41.1 () to
43.5 () y

MF (L4/L5L5/S1)

Mazis et al38

9 and 8 cadavers, 33 and 31


mean age 39.8-41.1 y undergoing IVD
surgery, mean
age 39.9-42.5

MF (L4/L5)

PAT: 67% type I


CON: 69% type I
No sig. differences between PAT
and CON
PAT : 60.3% type I, 21.8%
type IIa, 17.9% type IIx
PAT : 64.5% type I, 15% type
IIa, 20.5% type IIx
CON : 70.3% type I, 22.9%
type IIa, 17.9% type IIx
CON : 64.5% type I, 15% type
IIa, 20.5% type IIx
Sig. larger area occupied by type
IIa fibers in compared to
Sig. lower area occupied by type
I fibers in PAT compared to
CONSig. larger area occupied by
type IIX fibers in PAT compared
to CON

PAT : 57.7% type I


PAT : 62.5% type I
CON : 60.8% type I
CON : 62.5% type I
No sig. sex differences
No sig. differences between
PAT and CON
Sig. more type I fibers in CON No sig. sex differences
compared to PAT

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

7.2% to 22.34% for type IIx fibers, 26,30,35 whereas


percentages in thoracic muscles varied from 62% to
74.3% for type I, 17.45% to 27.3% for type IIa, and 4.6%
to 10.9% for type IIx fibers. 27,30 Only 2 articles compared the
muscle fiber type distribution between both regions: Mannion
et al 27 reported no significant differences between lumbar
and thoracic muscles, whereas Sirca and Kostevc 30 found
that MF and longissimus (LO) had significantly more type I

Screening

Identification

Journal of Manipulative and Physiological Therapeutics


Volume xx, Number

Cagnie et al
Review of Fiber Typing in Lumbar Muscles

Records identified through


Pubmed & Web of Science
(n = 214)

Additional records identified


through other sources
(n = 8)

Records after duplicates removed


(n = 207)

Included

Eligibility

Records screened
(n = 207)

Full-text articles assessed


for eligibility
(n = 38)

Records excluded
(n = 169)

Full-text articles excluded (n


= 20)
No adult humans: 2
Different outcome: 11
Inappropriate study design: 5
Multiple publications: 2

Studies included in
qualitative synthesis
(n = 18)

Fig 1. PRISMA flow diagram of the conducted search.

fibers at the T9 level (73.16%-74.3%) than MF and LO at the


L3 level (56.96%-63.21%).
The majority of articles investigated only lumbar muscle
fiber type distribution to compare different muscles or to
compare deep and superficial muscle layers, but findings
within these articles are divergent. Thorstensson and
Carlson 31 compared MF and LO of healthy subjects at
the L3 level but could not find significant differences
between both muscles. Neither could Rantanen et al 28 find
significant differences between MF and iliocostalis (IC) at
the L4/L5 level. This is in contrast with the findings of
Jrgensen et al 26 who found significantly more type I fibers
in LO (63.8%) compared to MF (59.4%) of healthy subjects
at the L3 level, but no significant differences for type IIa
and IIx fibers between both muscles. Jrgensen et al 26 also
investigated 6 male cadavers and found significantly more
type I fibers in LO (70%) compared to MF (54%) and IC
(55%) and significantly less type IIx fibers in LO (11.1%)
compared to MF (24%) and IC (25.6%). No significant
differences were found for type IIa fibers between the
lumbar muscles at the L3 level.
Only 3 articles distinguished deep from superficial
muscle layers in healthy subjects. Johnson et al 25 found
significantly more type II fibers in deep MF compared to
superficial MF in 3 subjects, more type II fibers in
superficial MF compared to deep MF in 1 subject, and no
significant differences in 2 subjects, whereas Sirca and
Kostevc 30 found significantly more type I fibers in deep
MF and LO (63.21%) compared to superficial MF and LO

(56.96%) at the L3 level. Rantanen et al 28 found no


differences at all between deep and superficial MF and IC.
Besides intraindividual variability, some articles investigated interindividual differences and sex differences in
particular. Although 5 articles 17,27,28,31,37 found no significant sex differences in muscle fiber type distribution, there
was 1 cadaver study 35 that reported significantly more type
IIa fibers in men (21.72%) compared to women (16.4%).
In summary, there is plausible evidence that there are no
differences in fiber type distribution between distinct
lumbar muscles and between healthy men and women
(strength of evidence 2). 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 (strength of evidence 3).
Low Back Pain Patients. Back muscles of patients with
LBP had a fiber type percentage ranging from 41% to 73%
of type I fibers, 16.1% to 25.84% of type IIa fibers, and
7.9% to 30.6% of type IIx fibers. 17,18,23,30
Most articles comparing lumbar muscles in patients
with LBP found no significant differences between
different muscles 24,29 or between deep and superficial
layers of the MF, LO, or sacrospinalis (SS). 23,29 Only
Sirca and Kostevc 30 found significantly more type I fibers
in deep MF (63.02%) compared to superficial MF
(56.38%) at the L3 level.
Four articles compared fiber type distribution between
the affected and the nonaffected side of patients undergoing

Cagnie et al
Review of Fiber Typing in Lumbar Muscles

IVD surgery. Two of those studies 24,34 did not find


significant side differences, whereas Yoshihara et al 32,33
found significantly more type I fibers on the affected side
(66%) compared to the nonaffected side (61%).
As for the healthy subjects, most patient studies 17,23,35,37
showed no sex differences in fiber type distribution. Yet, there is
1 article 18 that states that women have more type I fibers than
men (73% in women vs 65.4% in men) but that men have more
type IIx fibers than women (15.4% in men vs 10.4% in women).
In summary, there is plausible evidence that there are no
differences between lumbar muscles, muscle layers and
affected vs nonaffected sides in patients with LBP (strength
of evidence 2). In addition, there is plausible evidence that
there are no sex differences in fiber type distribution
(strength of evidence 2).
Low Back Pain Patients vs Healthy Controls. Two
articles, 1 comparing healthy subjects with chronic LBP
patients 36 and 1 comparing cadavers (with no known
history of LBP) with patients undergoing IVD surgery, 37
could not detect significant differences in fiber type
distribution. On the other hand, Bajek et al 35 found
significantly more type I (67.4%) and less type IIa
(18.16%) and IIx fibers (14.23%) in male patients
undergoing IVD surgery than male cadavers with no
known history of LBP (60.76% type I, 21.72 type IIa, and
17.48% IIx fibers). However, these results seemed sex
specific as they did not occur in women. Mannion et al 17
and Mazis et al, 38 on the other hand, stated that healthy
subjects have significantly more type I fibers than LBP
patients. Furthermore, the LBP patients of Mannion et al 17
showed significantly more type IIx fibers than the healthy
control subjects.
In summary, there is conflicting evidence about the fiber
type distribution between LBP patients and controls
(strength of evidence I).
Proportional Fiber Type Area (in Percentages). In addition to the
evaluation of fiber type distribution, some authors determined the relative proportional area occupied by each fiber
type. These percentages ranged from 54% to 80.3% for type
I, 11.8% to 32.4% for type IIa, and 2.8% to 23.7% for type
IIx fibers. 18,26,27,31
In healthy subjects, Thorstensson and Carlson 31 compared the proportional fiber type area for MF and LO, but
they found no significant differences.
Five articles compared the proportional fiber type area
between men and women. 17,18,27,31,38 Strikingly, only 1
study in LBP patients 38 could not find significant sex
differences, whereas the other 4 articles found a significantly larger area occupied by type I fibers in women
compared to men in both healthy subjects and LBP
patients. 17,18,27,31 Moreover, Mannion et al 17,18,27 found a
larger cross-sectional area occupied by type IIa and IIx
fibers in men compared to women. The type IIx fibers in
healthy female subjects were also found to be significantly

Journal of Manipulative and Physiological Therapeutics


Month 2015

more present in the lumbar region (6.2%) compared to the


thoracic region (2.8%), whereas the opposite was true for
the healthy male subjects (L3: 8.8% to T10: 10.1%). 27
Only 2 studies evaluated differences in proportional
fiber type area between LBP patients and healthy controls.
One could not demonstrate a significant difference between
both groups, 36 whereas the other found a significantly
smaller area occupied by type I fibers and a larger area
occupied by type IIx fibers in the LBP patients. 17
In conclusion, there is limited evidence that the
proportional fiber type area of MF and LO do not differ
from each other (strength of evidence 3) and conflicting
evidence about the proportional fiber type area between
LBP patients and healthy control subjects (strength of
evidence I). In contrast, there is plausible evidence that the
proportional cross-sectional area occupied by type I fibers is
higher in women compared to men (strength of evidence 2).

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

Journal of Manipulative and Physiological Therapeutics


Volume xx, Number

area occupied by type I fibers. Hence, it is interesting to


investigate this assumption in LBP patients. To our
knowledge, only 2 studies so far compared the proportional
fiber type area of LBP patients with healthy subjects. 17,36
Mannion et al 17 confirm the aforementioned assumption as
they found that severe LBP patients had a significantly
smaller area occupied by type I fibers and a significantly
larger area occupied by type IIx fibers compared to healthy
subjects. In contrast, Crossman et al 36 could not find
significant differences between both groups.
The added value of investigating the proportional fiber
type area is also confirmed by the fact that an alteration in
fiber size 1 (which is a determinant of proportional fiber type
area) is more likely to occur than an alteration in fiber type
distribution. 17,18,20,21 The fiber size is, in fact, easily
influenced through the protein metabolism, whereas fiber
type transformation requires cross innervation and stimulation, which usually not occurs by training or disuse. 20
Nonetheless, there are studies that have shown that LBP
patients tend to have more intermediate or hybrid fibers
(type IIC) than healthy subjects. These fibers exhibit both
type I and type II properties, suggesting an ongoing fiber
type transformation. 17,18 As long as no prospective studies
are carried out, the question remains whether the fiber
typing characteristics of LBP patients reflect changes due to
reflex inhibition or pain-induced inactivity and disuse or
whether these characteristics were present in advance.

Cagnie et al
Review of Fiber Typing in Lumbar Muscles

regarding cause and effect can be made. Therefore, it is


not known whether the changes identified in this review are
caused by LBP or whether the association between LBP and
muscle fiber typing are incidental.
Large-scale studies in this research field are currently
restricted as a consequence of the disadvantages inherent to
muscle biopsy. The invasiveness, indirect visualization, and
nonrepresentative sample sizes related to muscle biopsy
demand an alternative, noninvasive, and in vivo technique,
which would enable large-scale (prospective) studies.
Besides the discussion of the limitations of the published
literature, the current review process has also some
limitations which may have provided potential bias. Study
inclusion was limited to English, French, Dutch, and
German. Although this probably covers the field, potential
bias may have occurred by excluding studies based
upon language. Second, although key terms derived
from the PICO question were defined by 3 authors, the
screening based on title and abstract was done by only 1
author. Finally, all studies were scored using the EBRO
checklist. Although we are aware that this is not the most
recent and best checklist to use, to the best of our
knowledge, no optimal checklist is currently available for
scoring cross-sectional and case-control studies that are
not intervention-based.

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

In conclusion, it appears that the evidence regarding


muscle fiber typing in back muscles is either inconclusive
or indicative for little differences. The most plausible
evidence exists for differences in proportional fiber type
area depending on sex. Future large-scale studies using
alternative techniques are needed to clarify further the
association between LBP and muscle fiber typing.

FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST


Jessica Van Oosterwijck is a postdoctoral research
fellow funded by the Special Research Fund of Ghent
University. Kayleigh De Meulemeester is a research fellow
funded by the Special Research Fund of Ghent University.
No conflicts of interest were reported for this study.

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

Data collection/processing (responsible for experiments,


patient management, organization, or reporting data):
F.D., C.S., K.D., J.V.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): B.C.,
F.D., C.S., K.D., J.V.
Literature search (performed the literature search): F.D.,
C.S., K.D.
Writing (responsible for writing a substantive part of the
manuscript): B.C., F.D.
Critical review (revised manuscript for intellectual
content, this does not relate to spelling and grammar
checking): J.V., M.P., L.D.

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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