Partial resolution designation was for participants who reported a pain score of “1” on the final visit indicating that the participant was not reporting full resolution, and at least some degree of pain is present. Though often studied since, the exact mechanism for FR is not definitively known. At the initial experimental session with the LBP participants, the experimental nature of the measurements was discussed and that the protocol was not related to treatment was reinforced. Funding: The authors have no support or funding to report. https://doi.org/10.1371/journal.pone.0039207.g003. People who exhibit more extension-based back pain tend to have an over-active or dominate Posterior Extensor Chain (PEC Posture), and as weird as it sounds, (unloaded) flexion is one of the best ways to help them. It is likely that training effects within the ES could be in part responsible for changes in activation patterns. Men and women experiencing a LBP episode were recruited by means of advertisements posted at local clinicians' offices (physical therapists, chiropractors, and physicians) and by newspaper advertisement to participate in a maximum eight-week clinical study. Those experiencing a first episode of LBP of less than six months duration were better able to relax the lower lumbar erector spinae as their pain resolved and function improved. Repeat 3 times then turn over and do the other leg. One method reported for quantifying FR, to best allow comparison of measures repeated over time or between individuals, is to calculate the ratio of the sEMG amplitude of the ES during the trunk flexion phase to that recorded at full static flexion. This finding supports the observation generally reported throughout the literature of elevated sEMG amplitudes at full static flexion for those experiencing back pain [19]–[25], [27], [28], [30]. Surface EMG – Four differential surface electrodes and an amplification and conditioning system (Bagnoli-8 EMG System, Delsis Corp., Boston, MA) were used in this study. Hold for 5 seconds. It moves the lumbar spine through its full range of flexion and extension and is convenient enough to do anywhere. The experimental task, a flexion/extension motion starting in standing, was paced by a computer running a custom data acquisition program that produced a series of audible beeps. suggested that when the ES is electrically silent at full trunk flexion, passive tension of the muscle tissue could provide some resistance to trunk moment [4]. Thirty-four individuals meeting the study criteria for nonspecific back pain were enrolled and assigned to the LBP group. A unique feature of the present study was the ability, by virtue of the repeated measures, to observe the interplay between a physiologic measure, and self-reported measures of pain and function over the course of the low back pain episode in a high functioning population. Wrote the paper: RM JHL. Return to your original position and then lean obliquely (over one knee), first to the right and then to the left, repeating the bobbing procedure. Be careful not to arch your back, or conversely lean forward as you swing your heel. Stop immediately if it provokes pain or symptoms down your leg. Within the FL and EX phases the peak amplitude of each of the four EMG sites was determined, and the mean for a one-second window about the peak was taken as the sEMG amplitude value. No, Is the Subject Area "Metaanalysis" applicable to this article? Place the blunt end of a pencil on your navel (umbilicus / belly button). Repeat 20-30 times for each leg, then try the same thing again but this time with the foot turned slightly outwards. Correlations were generally stronger for some groups, in the analysis of groups based on history pain behavior and symptom resolution. Higher ratios indicate relatively more flexion relaxation (less activation) of the erector spinae at full trunk flexion. This significant relationship, though not providing as strong a correlation between measures, also makes sense in that light. Lumbar flexion has been shown to be an effective exercise for spinal stenosis, spondylolisthesis, and lumbar facet joint problems. 1, 28, 30]. A gain of 1000 was used. For both variables Tukey's post hoc testing show significantly greater correlations for both pain and function in the Transient group than for the Chronic group. Ratios of EMG amplitudes recorded during forward bending to amplitudes at full flexion, and ratios of extension to full flexion were calculated. Subgroups of lumbo-pelvic flexion kinematics are present in people with and without persistent low back pain BMC Musculoskelet Disord. Further, there are no reports in the literature of the nature of, or changes to FR-related measures using repeated measures over the course of an LBP episode. One might speculate that as their muscle physiology returned to a more “normal” status, their perceived pain and reported functional status responded accordingly. Tossing in some dedicated breathing drills which help teach people to “breath into their back” can make a world of difference. The electrodes, with an inter-electrode distance of 1 cm, had onboard amplification with a frequency response of 20 to 450 Hz, and a common mode rejection ratio of 92 dB. Whether changes were secondary to the natural history, or secondary to treatment or other factors should not be of significant concern as the study investigated correlation of pain or function to EMG- derived variables, independent of potential cause. For intermediate levels.Bring both knees towards your chest by actively contracting your hip muscles. The mean was then taken for the means for the left and right L2 sEMG, and the left and right L5 sEMG, yielding six measures used in the analysis: L2 and L5 amplitude during flexion (FLL2, FLL5), L2 and L5 amplitude during the flexion relaxation (FRL2, FRL5) and L2 and L5 amplitude during extension (EXL2 and EXL5). (20) Patients are required to perform home self-management exercises until their symptoms are abolished. Three replications of the motion were performed. The clinical investigation was conducted according to the principles expressed in the Declaration of Helsinki. The observation of electrical silence of the erector spinae (ES) at full trunk flexion was first referred to as flexion relaxation (FR) by Floyd and Silver [1]. Figure 4 shows bar graphs of FL-FRL2 and FL-FRL5 and EX-FRL2 and EX-FRL5 ratios for the Control group and for LBP groups recorded at the initial visit. Yes Exercises are designed to (1) strengthen the abdominal, gluteal, and quadriceps muscles, and (2) stretch the erector spinae, hamstring, and tensor fasciae latae muscles and iliofemoral ligament. It is the 5th most common reason people visit a Physician in the U.S. Electrodes were oriented along the long axis of the muscle and attached using skin tape. Kneeling down on all fours, with your head pointing straight ahead, lift the opposite arm and leg, keeping them as straight as you can. Copyright: © 2012 McGorry, Lin. While the studies cited above have focused on FR-related measures as a method to distinguish individuals with and without LBP, or as a method for documenting or guiding rehabilitation of those with chronic LBP, few studies have attempted to correlate FR with measures of self-reported pain and/or disability [22], [24], [31]. [7], and has been widely adopted as a method for quantifying FR [8], [16]–[22]. These lower back pain stretches use back flexion stretches to help open up the joint spaces in the back to take pressure off the nerves. Evaluation of the effect of treatment of chronic back pain is often based on the patient's pain report. Improved understanding of these relationships may provide insight in clinical management of LBP. Have them start in a “good” position: An intermediate to advanced level exercise, not to be done if there is any pain. Geisser et al. Extension-based pain is related to hyperextension of the spine. It is a safe exercise to perform since it places minimal strain on your back and can be done while lying down. The inclinometer was located dorsally at the mid-thoracic region overlying the sixth thoracic spinous process, and this orientation allowed measurement of gross trunk flexion/extension. The primary purpose of the TBC approach is to identify features at baseline that predict responsiveness to four different treatment strategies. Gently swing your heel back 30 centimetres or so and at the end, squeeze your butt-cheek on that side for a second or so, then allow the leg to swing back to neutral. the pain is better in your foot than in your knee). The selection criteria were that participants be 18 to 65 years of age, in good health and had no significant history of back pain. Hold for 10 seconds. Group assignments were made for participants with LBP based on two factors. Repeat 3 times. Using a custom software program one research team member marked four inflection points of the inclinometer tracing dividing the experimental task into three phases: the flexion phase (FL), the static fully flexed or flexion relaxation (FR) phase and the extension phase (EX). Though the reason for this is not known, it has been reported that flexion relaxation occurs less consistently in progression in a cephalad (towards the head) direction [3]. Sit on the floor and tuck one foot into your centre. For your first 1-2 weeks, use Part 1. PLOS ONE promises fair, rigorous peer review, Flatten your low back into the wall. Pain arising from the musculoskeletal system is the most common reason for individuals receiving Physiotherapy, 60% are treated for musculoskeletal pain, 25% of those are treated for Low Back Pain (LBP) making LBP the most common site of musculoskeletal pain. ANOVAs were conducted to test for differences between sEMG ratios recorded at the initial visit and final visits for participant groupings based on characteristics of their pain experience. and Ahern et al. Finally try extending your other leg so it lies flat on the floor. The Tukey's post hoc analysis showed significantly greater correlations for the Resolved group than for the Unresolved group. The literature shows that, in some but not all individuals for whom FR was absent (electrical silence did not occur at full flexion) while experiencing an episode of LBP, FR was reestablished when their symptoms resolved [1], [24]–[26]. Option B – Flexion-Based Strengthening – Pain while arching your back? The speculations made above could apply as well to these results. The results should provide some clinical insight for the practitioner in treatment of the individual experiencing an episode of non-specific LBP. At our clinic most chronic back pain patients will be given various combinations of the exercises rather than the whole lot, so it is not necessary to do them all to get some improvement. The three group assignments were Transient, Recurrent, and Chronic. Use flexion-based exercises and yoga postures to help strengthen your body without arching your spine. e39207. These measures and their relationships will also be compared to those obtained in a symptom-free control group. This questionnaire rates impairment on a 0 to 5 scale, with each point anchored by a functional rating ranging from “unable to perform activity” to “no difficulty” for 12 activities, providing a functional continuum from 0 representing total dysfunction to 60, normal function. https://doi.org/10.1371/journal.pone.0039207.g002. It can be increased in depth and duration to provide a greater challenge to those of  intermediate level ability. We'll assume you're ok with this, but you can opt-out if you wish. Discover a faster, simpler path to publishing in a high-quality journal. Their purpose is to stabilise the trunk posture by stretching and elongating tight muscles such the back extensors, hamstrings and hip flexors (i.e. First of all raise one knee toward your chest, by actively contracting your hip muscles. This technique, commonly referred to the “flexion relaxation ratio,” or similar terminology, was first reported by Sihvonen et al. ANOVA revealed no significant differences between any of the four sEMG ratios recorded on the first and last visits, for any of the three groups. Bend slowly forward from your back and be sure to stop just before you feel your pants start to slide up the wall. No significant differences between groups were found except at the L5 location at full flexion. As you become more aware of the contraction, you can eliminate the use of a pencil. However, though the tendency was similar, the correlation to EX-FRL5 was not significant (p = 0.058). This muscle is particularly weak in many people owing to their sedentary lifestyles. Begin by bringing your knees up to your chest, and grasping them with your hands. Draw the pencil inwards toward the floor and feel the contraction of muscles as you do so. 2018 Aug 28;19(1):309. doi: 10.1186/s12891-018-2233-1. The two levels of pain status were LBP and Control (no-LBP). No significant differences were observed for either flexion or extension ratios at the L2 level. At the initial session the LBP group reported a pain score of 3.0 (1.6) and a function score of 43.9 (8.0) on the BPFS scale. LBP affects at least 80% of us at some point in our lives. Then gradually slide down the wall till your thighs are parallel to the ground. Stand with your feet shoulder width apart, knees slightly bent and the small of your back flat up against a wall. Williams’ flexion exercises are meant to restore balance by strengthening abdominal, hamstring and gluteal muscles while stretching muscles of the back and hips. posture, electrode placement) [1], [5]–[10]. Using various FR-related measures of trunk flexion/extension in standing, several reports show differences between normal (pain-free) and LBP groups [7], [8], [11], [16], [23]. The sEMG amplitudes recorded at the two lumbar levels for the three phases of the experimental task are presented in Figure 3 for the Control and LBP groups at the initial visit. Objectives In patients with chronic low back pain (CLBP), reduced lumbar flexion-relaxation and reduced variability of muscle activity distribution are reported as abnormal muscle activity. LBP group participants were scheduled for eight visits distributed over an eight week period scheduled twice a week for the first two weeks, once a week for the third and fourth weeks and once each in the sixth and eighth weeks. The inclinometer signal for each trial, filtered with a 4th order zero-lag low pass Butterworth filter with an 8 Hz cutoff, was displayed on the computer screen. Eighteen participants were recruited for the Control group. The second grouping was based on the degree of improvement in LBP symptoms, or “pain resolution”, reported over the period of study participation. Conversely, those whose symptoms and functional deficits persisted throughout the course of the study had significantly weaker relationships with muscle activation patterns, being unable to alter those patterns when at full trunk flexion in response to changes in pain, and ultimately function. In those facing more prolonged experience with low back pain a dissociation seems to develop between physical behaviors and perception of pain as well as function in daily living. Competing interests: The authors have declared that no competing interests exist. Yes The mean amplitudes occurring during trunk extension when returning to the standing posture (concentric contraction) were generally greater than for the observed for the eccentric contraction of the initial flexion phase. No significant between-group differences were observed at the L2 level. Twenty-seven participants completed the full eight-session protocol. Citation: McGorry RW, Lin J-H (2012) Flexion Relaxation and Its Relation to Pain and Function over the Duration of a Back Pain Episode. You do not need to swing forward. Other research suggests that those with chronic, nonspecifc LBP were less efficient and thus used more energy in controlling postural sway than healthy individuals [36]. here. Hold for 10 seconds then slide back up the wall. The lumbodorsal fascia and other ligaments might provide the necessary supporting moment for the trunk, reducing the necessity of active muscular contraction to maintain the fully flexed posture [3]. The groupings based on the relative resolution of LBP over the reporting period produced similar trends. Reconciling spinal flexion and pain: we are all doomed to failure but perhaps it doesn't matter . Four sEMG signals and the inclinometer output were sampled at 1000 Hz and stored in computer memory. The correlations of the Partial resolution group were not significantly different than for either other group. Flexion based pain and dysfunction is most prevalent within our Americanized culture full of sitting, slouching, and overall piss-poor posturing. For the LBP group and the four members of the Control group that participated in the eight-week protocol, the electrode locations and skin landmarks were transferred to a transparent plastic film to permit consistent repositioning during subsequent sessions. Extension-based pain is usually experienced in the spinal facet joints, rather than the intervertebral discs; other common flexion-related injuries include spondyloisthesis and spinal stenosis. The groupings based on pain resolution produced similar trends among the correlation coefficients as did the pain history analysis. The following is a comprehensive series of low back pain exercises modified and expanded from several different sources. The purpose and protocol for the study was explained to all respondents, and those that expressed interest completed a medical history form and were interviewed and examined by a health care provider. Begin by raising both knees toward your chest, by actively contracting your hip muscles. A stopping criterion was used for LBP participants whose pain resolved during the course of the experimental protocol. Flexion-based pain is the most ubiquitous back pain of our age- the kind related to being hunched over computers and cell phones; the kind related to sitting more and doing less. On the opposite end of the spinal spectrum, extension-based dysfunction presents more in active populations, especially those stuck in an anteriorly tilted pelvic position for extended periods of time. In the protocol, starting from standing participants bent forward to a fully flexed posture, and then extended the trunk to return to standing position. B – flexion-based strengthening – pain while arching your back, with knees bent of pain into.! Or surgery, please do not lift your hips off the wall till your thighs are to... Healthy individuals as full trunk flexion phase than the Control and LBP group completed the multi-session protocol at! Often studied since, the correlation coefficients as did the pain history ”. 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