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26.8.

2016

Flexionrelaxationresponse&lowbackpain

Flexionrelaxationresponse&lowbackpain
ThereisagrowingbodyofliteratureexploringtheEMGactivitydifferencesofthetrunkmusclesbetween
individualswithlowbackpainandwithout.Eachstudytryingtodetermine:ifEMGdifferencesexist,ifthey
differdependingonthecauseoflowbackpain,ifEMGactivityisareliableobjectivemeasureforlowback
pain,andiftreatmentchangestheseEMGlevels.
WhenIfirstheardofthesestudiesIhadwasn'tentirelysurehowEMGstudiesrelatedtomyclinical
assessmentofLBPorhowIwasabletomeasureEMGlevelsinthetreatmentroom?Itwasn'tuntilItookat
masterclasswithRobLaird,SpecialistMusculoskeletalPhysiotherapistfromSuperSpine(Melbourne),thatI
begantounderstandhowitallfitstogether.IfweweretomeasureEMGactivityitwouldtellusnotabout
strengthoflumbarerectorspinaemuscles,butoftheactivationpatterns.

IfirstmetRobin2013duringhismasterclassontheassessmentofthelumbarspine.Atthispointinmy
career,IhadbeintroducedtotheO'SullivanClassificationfornonspecificLBPandRobspokeabout
thismodelasapartofhisclinicalpracticebutalsointroducedmetotheflexionrelaxationresponse
(FRR).Thisisnotanewphenomenon.Actually,ithasbeenresearchedsincethemid1950'sbutforsome
reason,Idon'trememberbeingtaughtitatUniversity.Alwaysabitscepticaloflearningsomethingnew,I
initiallywasn'tsurehowimportanttheFRRwas?WhatImeanbythisisthat,ifIcouldseefromthewaymy
patientsmovedthattheirmuscularpatternsweren'tcorrect,didIneedtoquantifythatinordertotreatit?
Well,Robaskedsomebrilliantquestionswhichhavestayedwithmesinceandopenedmyeyestohowdeep
ourclinicalreasoningcanbecome.

DecipheringthedrivingmechanismsbehindLBP
Let'sbacktrackalittle....
Q:ApatientpresentswithLBP...isitaspecificornonspecificproblem?A:Nonspecific.
Q:Isthepaincentrallyorperipherallydriven?A:peripherally.
Q:DothathaveLBPorpelvicgirdlepain?A:Lowbackpain
Q:Aretheirmovementpatternsadaptiveormaladaptive?A:Maladaptive.
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Q:Dotheyhaveacontrolimpairmentormovementimpairments?A:Amovementimpairments
characterisedbyhighlevelsofmuscleguardingandcocontractions.
Q:Whatdirectionismostprovocative?A:forwardbending(flexion).
Q:Whatdoyouseewhenyoubendforward?
Q:Howcanyouobjectivelymeasurethis?
Q:Howcanyouprovethisisrelatedtotheirpain?
Q:Howdoyouknowifthemovementpatternisnormalornot?
Q:Willmodifyingtheirmovementpatternhelp?
Thisisahypotheticalcasebutseehowtheanswersstopped?Well,thatisareflectionofwheremythinking
wasuptobeforeImetRob.Ithoughtthepuzzlewassolved.WheninfactRobshowedmethatthe
questionscontinueandmoreimportantly,thatwearestillsearchingforthescientific/researchanswersto
someofthem.
WhatwehavelearntovertimeisthatLBPisnotahomogenousgroupofconditions.We'velearntthatsome
peoplehavespecificpathoanatomicalorstructuralcausestotheirpainwhileothersdon't.We'velearntthat
sometimesourdeepstabilisingmusclesstarttobehavedifferently,butnotineveryone.We'vealsorealised
thatmovementpatternscanbepaindriverstoo.Nowweareinsearchofthebestwaytodeterminewhy
maladaptivemovementpatternsariseandiftheyaremodifiableandwhatwecandoaboutit?This
comesdowntotheconceptofmodifiablemovementpatterns.
Lumbopelvicrhythmisthecoordinatedmovementbetweenthelumbarspineandhipjoints,connectedby
thepelvis,thatallowsustomoveourtrunk(Kim.,2013).Oftenthatcoordinationofmovementcanbe
alteredandleadtoloadinstaticpositions,loadthroughrangeandendrangeloadonstructuresinthe
lumbarspine.Unfortunately,thereisnoconsistentmovementpatternthatmatchesbackpainandeveryone
movesslightlydifferentlyjustasthecauseofpainvariesbetweenindividuals.Unfortunatelyitcan'tbea'one
sizefitsall'approach.
Thepurposeofthisblogistoexplorethesefewquestions.
Whatistheflexionrelaxationresponse(FRR)?
Whatdoyouseeandhowcanyoumeasureit?
WhatstrategiesdowehavetorestoreanormalFRR?

Whatistheflexionrelaxationresponse(FRR)?
Duringflexiontheerectorspinaemusclesacteccentricallytocontrolflexionuntiltheveryendofrange,
wherethereisasuddendecreaseinmuscleactivity.Thisisreferredtoastheflexionrelaxationresponse
(FRR),andisimportantforachievingfullrange(Kim,etal.,2013Zwambag&Brown,2015).

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Ideally,duringnormalmovementlumbarflexionisinitiatedbythelumbarspine.Duringthefirsthalfof
availablerangethemovementisledbythelumbarspine.Followingthisandtowardstheendofforward
bending,thehipsbegintocontributemoretotheavailablerange.TheFRRisimportantforallowingthefull
expressionoflumbarflexiontooccurandhasbeenreliablefoundtooccurinnormalsubjects(Neblett,etal.,
2014).
Researchhasshownthatwhentheparaspinalmusclescomeintostretchtheytriggermechanoreceptorsin
thejointsandpassivestructures.Thisinturntriggersastressinhibitionreflextooccur,causingthe
paraspinalmusclestobecomeinhibitedandthepassivestructurescontinuetoprovidethestabilityatthe
endofrange(Kim,etal.,2013).Thisisdescribedasaloadsharingmechanismbetweenactiveand
passivestructures(Zwambag&Brown,2015).Theangleatwhichthisphenomenonoccursisoftenreferred
toastheabsoluteflexionangle(Zwambag&Brown,2015).
SomestudiesexploringtheFRRhasfoundthatpatientswithlowbackpainareoftenoveractivethrough
theirlumbarerectorspinaemuscles,whichhardlyswitchoff,andtheorisethatthisoveractivation
contributestooverloadingofthespineandalteredloadsharingcapabilityofthetissues(Kim,etal.,2016).
Thus,iftheFRRisavitalpartofmovementintoflexionandstudieshaveshownthatitcanbeabsentor
altered,thenitbegsthequestionsofhowwearecurrentlymeasuringmovementpatternsinthelumbar
spineduringassessment?

WHATDOYOUSEEANDHOWCANYOUMEASUREIT?
Intheclinicyoumightuseagoniometerforrangeofmovement,measurefingertipstofloor,orhowfarthe
handsslidedowntheshins.Experimentally,somestudiesuse3Dvideoanalysistomeasurerangeand
contributiontomovementofthelumbarspine,hipandpelvis,andsurfaceEMGtounderstandmuscle
activity(Kim,etal.2013).AmetaanalysishasshownthatsurfaceEMGcombinedwithROManalysiscan
increasethesensitivity(88.8%)andspecificity(81.3%)ofassessment(Geisser,etal.,2005,p.721).
Essentiallywhatthismeansisthatweneedtocontinuetolookforwaystoimproveourmeasureinorderto
determinewhattypeofmovementpatternwearetryingtotreat.

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TherearedevicesonthemarketwhichmeasureEMGactivityduringstaticanddynamicmovements,butthe
reliabilityandclinicalutilityofthesearecurrentlybeingexploredbutresearcherssuchasRob.Clinically,I
stillrelyonvisualobservationasmymainmeasureofrangeofmovementbutnowIlookatafewmore
elementsthanpreviously.
1.Howmuchrangedotheyhave?
2.Whatisthelimitingfactorpain,stiffness,endofmovement?
3.Whatdoestheirmovementlooklike?Aretheyflatthroughtheirbackorveryrounded?Dothey
useboththelumbarspineandhipsduringrange?
Sometimesitiseasytoseetheproblembutothertimesitisdisguised.Irememberduringthemasterclass
Robshowingaseriesofvideosandaskingustodescribeifwethoughtthemovementwascomingfromthe
spine,orhipsorboth.Onseveraloccasions,whatlookedlikelimitedlumbarflexionwasactuallytoomuch
lumbarflexionorviceversa.Essentially,thepointthatRobwastryingtoshowusisthatoureyesdon't
alwaysseeexactlywhatisgoingonandwherethemovementiscomingfromandperhaps,devicesthat
measureEMGactivityduringdifferentrangesofmovementcanassistourassessment.Itisimportantduring
assessmenttobeconsistent.Whichevermethodsyouchoose,tryusetheminareproduciblemanner.

WhatstrategiesdowehavetorestoreanormalFRR?
OnceyouhavemeasuredlumbaractiverangeofmovementanddeterminedthattheFRRisimpaired,you
nextneedtotrydeterminewhatthelimitingfactoris.Isflexionpainfulandlimitedbecausethehipsaren't
contributingenough?Inthatcase,whatfactorsareimpedehipflexion?Or,isthelumbarspineremainingin
toomuchextensionandwhywouldthatbethecase?
Ideally,youwillalwaystakethemovementpatternintoconsiderationasacomponentoftheentire
assessment.Forexample,thepatientmightbeoverusingtheirlumbarspinebuttheyhaveahypermobility
syndromeandtheirmechanoreceptorsdon'tgetactivatedbecausetheirjointsandligamentsaren'ton
stretchattheendofrange.Logically,continuingtomovethesepatientsintoflexionmightnotbeagreat
approach.Alternatively,repeatingmovementintoflexionmightalsonotbeagreatapproachwhenapatient
usestoomuchlumbarrangebecausetheyhavetightnessthroughtheposteriorstructuresofthethehipthat
preventhipflexion.
Therefore,youmightaddresscontributingfactorssuchasflexibilityintheposteriorhipstructuressuchas
calves,hamstrings,glutealsandstructuresintheposteriorchain.Youmaywishtoloosenanytightened
structuresinlumbarspinecontributingtoitstayinginrelativeextension.Or,youmighttryretrainthe
lumbarflexionmovementpattern.Thislastapproachcanbedowninprogressiveways:

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Child'spose

Seatedforwardflexion

Standingforwardflexion
Whenretrainingflexionrememberthatthemainfocusistoencouragerelaxationattheendofrange.If
thepatientisguardedorexperiencingpain,thentheexercisepositionisnotappropriate.I'vealwaysbegun
withchild'sposeasitaddressesalltheelementsweneedi.ehipflexion,lumbarflexionandthefloor
supportsthepatientallowingthemtofocusontheirbreathing.Oncerelaxationisachievedinthisposition,
theseatedforwardfoldisthenextstepandpatient'shavetheirupperbodysupportedastheyrestontheir
thighs.Again,focussingonbreathingandlettinggo.Thefinalprogressionisintheposturetheyoriginally
foundprovocativeandthiswouldbedowninthelaterstagesofrehab.
Whatifthemovementispainfulandyoucan'tusethesetechniques?
Ifthesemovementsaretoopainfuloruncomfortableforyourclient,andyoustillbelievetheyneedmore
relaxationthroughthelumbarerectorspinae,thenIhavefoundlumbarrotationtobeagreatalternative.
Whatweknowaboutthebackmusclesisthattheyworkbilaterallytocreateextensionandunilaterallyto
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createrotation.Soaswerotatefromsidetoside,onesideisactivatingandtheotherrelaxing.It'sagood
startingpointtogainrelaxationofmuscles,encouragingcontrolofmovement,teachbreathingcontrolina
painfreeposition.

HopefullythisbloghasgivenyousomenewtoolsinthetreatmentofLBP.Itisnothingneworfancybuta
strongremindertotaketimetoperformathoroughandcarefulassessmentofthemainproblemandthe
movementpatternsaroundthat.
Forme,itisareinforcementthatweconstantlyneedtobelinkingassessmentandtreatmentandproving
thatstrategiesarehelpful.Whilewecontinuetosearchfordataandanswers,wejustneedtofocuson
applyingourclinicalreasoningtochoosethebesttreatmentforthebestperson.Idefinitelythinkthisisa
"watchthisspace"topicandthatinthenearfuturewewillhavedevelopedandresearchedbetterwaysto
objectivelymeasurelumbarmovement,analysethemovementpatternswefind,andstrategiesfor
normalisingtheflexionrelaxationresponse.
Sian:)
References:
Geisser,M.E.,Ranavaya,M.,Haig,A.J.,Roth,R.S.,Zucker,R.,Ambroz,C.,&Caruso,M.(2005).Ameta
analyticreviewofsurfaceelectromyographyamongpersonswithlowbackpainandnormal,healthy
controls.Thejournalofpain,6(11),711726.
Hu,B.,Shan,X.,Zhou,J.,&Ning,X.(2014).Theeffectsofstancewidthandfootpostureonlumbarmuscle
flexionrelaxationphenomenon.ClinicalBiomechanics,29(3),311316.

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Kim,M.H.,Yi,C.H.,Kwon,O.Y.,Cho,S.H.,Cynn,H.S.,Kim,Y.H.,...&Jung,D.H.(2013).Comparisonof
lumbopelvicrhythmandflexionrelaxationresponsebetween2differentlowbackpain
subtypes.Spine,38(15),12601267.
Laird,R.A.,Kent,P.,&Keating,J.L.(2012).Modifyingpatternsofmovementinpeoplewithlowbackpain
doesithelp?Asystematicreview.BMCmusculoskeletaldisorders,13(1),1.
Neblett,R.,Mayer,T.G.,Brede,E.,&Gatchel,R.J.(2014).Theeffectofpriorlumbarsurgeriesonthe
flexionrelaxationphenomenonanditsresponsivenesstorehabilitativetreatment.TheSpineJournal,14(6),
892902.
Zwambag,D.P.,&Brown,S.H.(2015).Factorstoconsiderinidentifyingcriticalpointsinlumbarspine
flexionrelaxation.JournalofElectromyographyandKinesiology,25(6),914918.

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