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Risk factors and determinants of Low Back Pain: The Deconditioning Cycle

Musculoskeletal disorders are the biggest cause of disability. Despite the billions spent, the problem is just getting worse. Latest medical guidelines strongly recommend exercise therapy as the first-line-treatment for musculoskeletal disorders instead of much more expensive surgeries.

By Professor Emeritus John Carlson, Co-Founder of getback

Back pain is so prevalent that it can strike even if you have no risk factors, but research reveals there is some commonality among chronic back pain patients.

Many risk factors for back pain have been identified, including ageing, genetics, occupational hazards, lifestyle, weight, posture, pregnancy and smoking. 

In my previous blog I focused on the role of the Deep muscle group (Multifidus) in back stability and the occurrence of back pain. 

At getback our treatment approach and protocols are based on biomechanical research evidence which identifies both the interplay between the Deep and Superficial muscles and the vast amount of physiological and clinical evidence of muscle impairment (decreased strength and endurance) in chronic back and neck pain patients.

Research on the spinal muscle system has focused not only on its torque producing role, but its function to control and support the spinal segments. It has been shown that Deep muscle (Multifidus) activity is required in synergy with Superficial muscle activity to stabilise the segments, especially in functional mid ranges. 

The endurance capacity and properties of the small Superficial musculature means they are the first to become fatigued in tests of flexion, extension and lateral flexion. These movement combinations are often described by patients who experience pain episodes while exercising (for example, gardening or other recreational activities).

There is also clear evidence of Deep muscle dysfunction in neuromotor control in chronic low back pain patients. Jull (2000) states that the Deep muscles are significant not only for segmental support of the spine, but also may be key muscles affected in patients with chronic low back and neck pain.

The evidence shows that factors such as weakness, fatigue and loss of control in the Deep muscles are associated with degeneration and injury. 

At getback, we emphasise that these muscles can be returned to functional limits and provide segmental support through increased muscular control and specific, targeted and precise staged overload progression.

Although the cause of spinal pain can be multifactorial, there are common contributing functional factors as we have identified above.

Observations from clinical practice also reveal that low back pain has a strong tendency to recur. This low back pain is neither acute nor chronic but fluctuates over time, with frequent recurrences or exacerbations. There will be continued ‘ups and downs’ in the severity of pain and in the timing of episodes (Figure A). 

Figure A: Typical ups and downs of back pain

The prevalence of low back pain is noticeably more common in individuals who have had pain episodes in the past, than in individuals who have not experienced them before. 

Most episodes of low back pain are transient phenomena and do not cause significant problems in isolation. The situation becomes more problematic if the pain is prolonged and becomes chronic: the patient enters a cycle which, if not broken, can lead to atrophy (weakness and decrease in muscle mass) of the supporting musculature, loss of movement function and concurrent psychosocial upset. 

It has been shown that atrophy of the paraspinal muscles can be initiated in the first episode of back pain, resulting from the reduction in proteins responsible for the building and structure of muscles.

When a patient injures themselves in an acute incident, the back pain rapidly invokes spasm reactions and reflex inhibition of the deep spinal muscles. If acute pain caused by tissue damage becomes prolonged, widespread deficits in motor control may develop. They may cause excess spasm activity of the spinal muscles, delay in the reaction reflexes of trunk muscles and deficits in their co-ordination, compensatory posture and balance control.

If a Deconditioning Cycle of maladaptation develops, pain and functional deficits in the Deep spinal muscles leads to underutilisation of the back. Due to avoidance behavior, volitional back motions become limited and muscle strength and endurance are subsequently lost. This in turn leads to functional disability that maintains the patient’s pain. 

The inevitable downward spiral of this Deconditioning Cycle can result in ongoing functional disability and chronic low back disorder.

The diagram at right depicts the effects of the cycle if deconditioning is not arrested. In future blogs we will specifically address how the getback rehabilitation system addresses this issue.