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1.  Effects of Static Flexion-relaxation on Paraspinal Reflex Behavior 
Background.
Static trunk flexion working postures and disturbed trunk muscle reflexes are related to increased risk of low-back pain. Animal studies conclude that these factors may be related; passive tissue strain in spinal ligaments causes subsequent short-term changes in reflex. Although studies have documented changes in the myoelectric onset angle of flexion-relaxation following prolonged static flexion and cyclic flexion we could find no published evidence related to the human reflex response of the trunk extensor muscles following a period of static flexion-relaxation loading.
Methods.
Eighteen subjects maintained static lumbar flexion for 15 min. Paraspinal muscle reflexes were elicited both before and after the flexion-relaxation protocol using pseudorandom stochastic force disturbances while recording EMG. Reflex gain was computed from the peak value of the impulse response function relating input force perturbation to EMG response using time-domain deconvolution analyses.
Findings.
Reflexes showed a trend toward increased gain after the period of flexion-relaxation (P < 0.055) and were increased with trunk extension exertion (P < 0.021). Significant gender differences in reflex gain were observed (P < 0.01).
Interpretations.
Occupational activities requiring extended periods of trunk flexion contribute to changes in reflex behavior of the paraspinal muscles. Results suggest potential mechanisms by which flexed posture work may contribute to low-back pain. Significant gender differences indicate risk analyses should consider personal factors when considering neuromuscular behavior.
doi:10.1016/j.clinbiomech.2004.09.001
PMCID: PMC1630677  PMID: 15567532
Low-back; Reflex; Flexion-relaxation
2.  Disturbed Paraspinal Reflex Following Prolonged Flexion-Relaxation and Recovery 
Spine  2006;31(7):839-845.
Study Design.
Repeated measures experimental study of the effect of flexion-relaxation, recovery, and gender on paraspinal reflex dynamics.
Objective.
To determine the effect of prolonged flexion-relaxation and recovery time on reflex behavior in human subjects.
Summary of Background Data.
Prolonged spinal flexion has been shown to disturb the paraspinal reflex activity in both animals and human beings. Laxity in passive tissues of the spine from flexion strain may contribute to desensitization of mechanoreceptors. Animal studies indicate that recovery of reflexes may take up to several hours. Little is known about human paraspinal reflex behavior following flexion tasks or the recovery of reflex behavior following the flexion tasks.
Methods.
A total of 25 subjects performed static flexionrelaxation tasks. Paraspinal muscle reflexes were recorded before and immediately after flexion-relaxation and after a recovery period. Reflexes were quantified from systems identification analyses of electromyographic response in relation to pseudorandom force disturbances applied to the trunk.
Results.
Trunk angle measured during flexion-relaxation postures was significantly higher following static flexion-relaxation tasks (P < 0.001), indicating creep deformation of passive supporting structures in the trunk. Reflex response was diminished following flexion-relaxation (P < 0.029) and failed to recover to baseline levels during 16 minutes of recovery.
Conclusion.
Reduced reflex may indicate that the spine is less stable following prolonged flexion-relaxation and, therefore, susceptible to injury. The absence of recovery in reflex after a substantial time indicates that increased low back pain risk from flexion-relaxation may persist after the end of the flexion task.
doi:10.1097/01.brs.0000206361.53451.c7
PMCID: PMC1808336  PMID: 16582860
flexion-relaxation; reflex; low back; spine; electromyogram; stability
3.  Effects of Exercise Induced Low Back Pain on Intrinsic Trunk Stiffness and Paraspinal Muscle Reflexes 
Journal of biomechanics  2012;46(4):801-805.
The purpose of this study was to 1) compare trunk neuromuscular behavior between individuals with no history of low back pain (LBP) and individuals who experience exercise-induced LBP (eiLBP) when pain free, and 2) investigate changes in trunk neuromuscular behavior with eiLBP. Seventeen young adult males participated including eight reporting recurrent, acute eiLBP and nine control participants reporting no history of LBP. Intrinsic trunk stiffness and paraspinal muscle reflex delay were determined in both groups using sudden trunk flexion position perturbations 1-2 days following exercise when the eiLBP participants were experiencing an episode of LBP (termed post-exercise) and 4-5 days following exercise when eiLBP had subsided (termed post-recovery). Post-recovery, when the eiLBP group was experiencing minimal LBP, trunk stiffness was 26% higher in the eiLBP group compared to the control group (p=0.033) and reflex delay was not different (p=0.969) between groups. Trunk stiffness did not change (p=0.826) within the eiLBP group from post-exercise to post-recovery, but decreased 22% within the control group (p=0.002). Reflex delay decreased 11% within the eiLBP group from post-exercise to post-recovery (p=0.013), and increased 15% within the control group (p=0.006). Although the neuromuscular mechanisms associated with eiLBP and chronic LBP may differ, these results suggest that previously-reported differences in trunk neuromuscular behavior between individuals with chronic LBP and healthy controls reflect a combination of inherent differences in neuromuscular behavior between these individuals as well as changes in neuromuscular behavior elicited by pain.
doi:10.1016/j.jbiomech.2012.11.023
PMCID: PMC3568223  PMID: 23182221
low back pain; exercise; trunk stiffness; reflex
4.  Age and gender related neuromuscular changes in trunk flexion-extension 
Background
The root mean square surface electromyographic activity of lumbar extensor muscles during dynamic trunk flexion and extension from a standing position and task specific spine ranges of motion objectively assess muscle function in healthy young and middle age individuals. However, literature on neuromuscular activation and associated spine and hip kinematics in older individuals is sparse. This cross sectional study sought to examine the sex and age (<40 versus >60 years) related differences in the neuromuscular activation profiles of the lumbar extensors and the related spine and hip kinematics from healthy individuals during a standardized trunk flexion-extension task.
Methods
Twenty five older (13 females, 60–90 years) and 24 younger (12 females, 18–40 years) healthy individuals performed trunk flexion-extension testing by holding static positions at half-flexion way and full range of motion between standing and maximum trunk flexion. The associated lumbar extensor muscle activity was derived from measurements at standing, half, and maximum flexion positions. The range of motion at the hip and lumbar spine was recorded using 3d accelerometers attached to the skin overlying the multifidus and semispinalis thoracis muscles lateral to the L5 and T4 spinous processes, respectively. Statistical calculations were performed using a permutation ANOVA with bootstrap confidence intervals.
Results
The muscle activity in the half related to the maximum flexion position (half flexion relaxation ratio) was significantly smaller in older males when compared with younger males. Moreover, measurements revealed smaller activity changes from standing to the half and from half to the maximum flexion position in older compared to younger individuals. Older males displayed smaller gross trunk range of motion from standing to maximum flexion than any other group.
Conclusions
Gender and normal aging significantly affect both the activation patterns of the lumbar extensor muscles and the kinematics of the trunk during a standardized trunk flexion-extension task. Measurement results from healthy young and middle age individuals should not be used for the assessment of individuals older than 60 years of age.
Electronic supplementary material
The online version of this article (doi:10.1186/1743-0003-12-3) contains supplementary material, which is available to authorized users.
doi:10.1186/1743-0003-12-3
PMCID: PMC4326518  PMID: 25566847
Lumbar extensor muscles; Trunk flexion-extension; Electromyography; Age; Gender; Kinematics
5.  Lumbar paraspinal and biceps brachii muscle function and movement perception in lumbar spinal stenosis 
European Spine Journal  2012;22(4):788-793.
Introduction
Impaired muscle function and lumbar proprioception have been observed in lumbar spinal stenosis (LSS) but those have not been studied in LSS patients with age-matched controls. We assessed lumbar movement perception and paraspinal and biceps brachii (BB) muscle responses during sudden upper limb loading in age-matched healthy subjects and patients with LSS.
Methods
The study included 30 patients selected for an operation due to LSS and 30 age-matched controls without chronic back pain. The paraspinal and BB muscle responses for upper limb loading during unexpected and expected conditions were measured by surface EMG. The ability to sense lumbar rotation was assessed in a previously validated motorized trunk rotation unit in a seated position. Pain, disability and depression scores were recorded.
Results
Patients had poorer lumbar perception (mean difference 2.3 ± 0.6°, P < 0.001) and longer paraspinal muscle response latencies [mean difference 4.6 ± 0.6 ms (P = 0.033)] than age-matched healthy controls. Anticipation increased paraspinal and BB muscle activation prior to the load perturbation (P < 0.001) but less in LSS patients than in controls [9 vs. 30 %, P = 0.016 (paraspinals); 68 vs. 118 %, P = 0.047 (BB)].
Conclusions
The observed impairments in lumbar proprioception and activation of paraspinal and upper limb muscles indicate an extensive loss of both sensory and motor functions in LSS. The main new finding was decreased anticipatory muscle activation during expected upper limb loading reflecting involvement of central movement control mechanisms.
doi:10.1007/s00586-012-2563-x
PMCID: PMC3631031  PMID: 23179975
Lumbar proprioception; Paraspinal reflexes; Feed-forward control; Low back pain; Lumbar spinal stenosis
6.  Comparison of trunk stiffness provided by different design characteristics of lumbosacral orthoses 
Background
Lumbosacral orthoses (LSOs) are class I medical devices that are used in conservative and postoperative management of low back pain. The effectiveness of LSOs depends on their design aimed at enhancing trunk stiffness. Therefore, the purpose of this study was to compare two lumbar supports: extensible (made of neoprene and lycra) and nonextensible (made of polyester and nylon).
Methods
Trunk stiffness and damping was estimated from trunk displacement data in response to a quick force release in trunk flexion, extension, and lateral bending. 14 male and 6 female subjects performed 5 trials at each experimental condition: 1) No LSO, 2) extensible LSO, 3) non-extensible LSO, 4) non-extensible LSO with a small rigid front panel, and 5) non-extensible LSO with a large rigid front panel. Testing order was randomized and the LSOs were cinched to a pressure of 70 mmHg (9.4 kPa) measured between posterior aspect of the iliac crest and the orthosis.
Findings
The non-extensible LSO reduced trunk displacement by 14% and increased trunk stiffness by 14% (p<0.001). The extensible LSO did not result in any significant change in trunk displacement or stiffness. The addition of rigid front panels to the non-extensible LSO did not improve its effectiveness. The trunk damping did not differ between the LSO conditions.
Interpretation
A non-extensible LSO is more effective in augmenting trunk stiffness and limiting trunk motion following a perturbation than an extensible LSO. The rigid front panels do not provide any additional trunk stiffness most likely due to incongruence created between the body and a brace.
doi:10.1016/j.clinbiomech.2009.10.010
PMCID: PMC2887766  PMID: 20004503
Lumbar Spine; Stability; Low Back Pain; Abdominal Belts
7.  Jogging Kinematics After Lumbar Paraspinal Muscle Fatigue 
Journal of Athletic Training  2009;44(5):475-481.
Abstract
Context:
Isolated lumbar paraspinal muscle fatigue causes lower extremity and postural control deficits.
Objective:
To describe the change in body position during gait after fatiguing lumbar extension exercises in persons with recurrent episodes of low back pain compared with healthy controls.
Design:
Case-control study.
Setting:
Motion analysis laboratory.
Patients or Other Participants:
Twenty-five recreationally active participants with a history of recurrent episodes of low back pain, matched by sex, height, and mass with 25 healthy controls.
Intervention(s):
We measured 3-dimensional lower extremity and trunk kinematics before and after fatiguing isometric lumbar paraspinal exercise.
Main Outcome Measure(s):
Measurements were taken while participants jogged on a custom-built treadmill surrounded by a 10-camera motion analysis system.
Results:
Group-by-time interactions were observed for lumbar lordosis and trunk angles (P < .05). A reduced lumbar spine extension angle was noted, reflecting a loss of lordosis and an increase in trunk flexion angle, indicating increased forward trunk lean, in healthy controls after fatiguing lumbar extension exercise. In contrast, persons with a history of recurrent low back pain exhibited a slight increase in spine extension, indicating a slightly more lordotic position of the lumbar spine, and a decrease in trunk flexion angles after fatiguing exercise. Regardless of group, participants experienced, on average, greater peak hip extension after lumbar paraspinal fatigue.
Conclusions:
Small differences in response may represent a necessary adaptation used by persons with recurrent low back pain to preserve gait function by stabilizing the spine and preventing inappropriate trunk and lumbar spine positioning.
doi:10.4085/1062-6050-44.5.475
PMCID: PMC2742456  PMID: 19771285
gait analysis; spine
8.  GENDER DIFFERENCES IN TRUNK, PELVIS AND LOWER LIMB KINEMATICS DURING A SINGLE LEG SQUAT 
Gait & posture  2012;36(3):461-466.
The relationship between trunk and lower limb kinematics in healthy females versus males is unclear since trunk kinematics in the frontal and transverse planes have not been systematically examined with lower limb kinematics. The aim of this study was to investigate the existence of different multi-joints movement strategies between genders during a single leg squat. We expected that compared to males, females would have greater trunk and pelvis displacement due to less trunk control and display hip and knee movement consistent with medial-collapse (i.e. greater hip adduction, hip medial rotation, knee abduction, knee lateral rotation) on the weight-bearing limb.
9 females and 10 males participated in the study. Kinematic data were collected using an 8-camera, 3D-motion-capture-system. Trunk relative to pelvis, pelvis relative to the laboratory, hip and knee angles in three planes (sagittal, frontal and transverse) were examined at two time events relevant to knee joint mechanics: 45° of knee flexion and peak knee flexion. Females flexed their trunk less than males and rotated their trunk and pelvis toward the weight-bearing limb more than males. Females also displayed greater hip adduction and knee abduction than males.
Taken together these results suggest that females and males used different movement strategies during a single leg squat. Females displayed a trunk and pelvic movement pattern that may put them at risk of knee injury and pain.
doi:10.1016/j.gaitpost.2012.04.006
PMCID: PMC3407338  PMID: 22591790
9.  Muscle Stiffness and Spinal Stretch Reflex Sensitivity in the Triceps Surae 
Journal of Athletic Training  2008;43(1):29-36.
Context: Greater musculotendinous stiffness may enhance spinal stretch reflex sensitivity by improving mechanical coupling of the muscle spindle and the stretch stimulus. This heightened sensitivity would correspond with a shorter latency and higher-amplitude reflex response, potentially enhancing joint stability.
Objective: To compare spinal stretch reflex latency and amplitude across groups that differed in musculotendinous stiffness.
Design: Static group comparisons.
Setting: Research laboratory.
Patients or Other Participants: Forty physically active individuals (20 men, 20 women).
Intervention(s): We verified a sex difference in musculotendinous stiffness and compared spinal stretch reflex latency and amplitude in high-stiffness (men) and low-stiffness (women) groups. We also evaluated relationships between musculotendinous stiffness and spinal stretch reflex latency and amplitude, respectively.
Main Outcome Measure(s): Triceps surae musculotendinous stiffness and soleus spinal stretch reflex latency and amplitude were assessed at 30% of a maximal voluntary isometric plantar-flexion contraction.
Results: The high-stiffness group demonstrated significantly greater stiffness (137.41 ± 26.99 N/cm) than the low-stiffness group did (91.06 ± 20.10 N/cm). However, reflex latency (high stiffness = 50.11 ± 2.07 milliseconds, low stiffness = 48.26 ± 2.40 milliseconds) and amplitude (high stiffness = 0.28% ± 0.12% maximum motor response, low stiffness = 0.31% ± 0.16% maximum motor response) did not differ significantly across stiffness groups. Neither reflex latency (r = .053, P = .746) nor amplitude (r = .073, P = .653) was related significantly to musculotendinous stiffness.
Conclusions: A moderate level of pretension (eg, 30%) likely eliminates series elastic slack; thus, a greater change in force per unit-of-length change (ie, heightened stiffness) would have minimal effects on coupling of the muscle spindle and the stretch stimulus and, therefore, on spinal stretch reflex sensitivity. It appears unlikely that differences in musculotendinous stiffness influenced spinal stretch reflex sensitivity when initiated from a moderate level of pretension. Consequently, differences in musculotendinous stiffness did not appear to influence dynamic joint stability with respect to reflexive neuromuscular control.
PMCID: PMC2231394  PMID: 18335010
latency; amplitude; material modulus; compliance; neuromuscular control
10.  Reflex control of ipsilateral and contralateral paraspinal muscles 
Homonymous and heteronymous reflex connections of the paraspinal muscles were investigated by the application of a tap to the muscle bellies of the lumbar multifidus and iliocostalis lumborum muscles and observation of surface electromyographic responses in the same muscles on both sides of the trunk. Reflexes were evoked in each of the homonymous muscles with latencies and estimated conduction velocities compatible with being evoked by Ia muscle afferents and having a monosynaptic component. Short latency heteronymous excitatory reflex connections were observed in muscles on the ipsilateral side, whilst reflex responses in the contralateral muscles were inhibitory in response to the same stimulus. The latencies of the crossed responses were on average 9.1 ms longer than the ipsilateral excitatory responses. These results are in contrast to the crossed excitatory responses observed between the abdominal muscles and trapezius muscles on the opposite aspect of the trunk. Such a difference in the reflex pathways between these two groups of trunk muscles compliments the different anatomical arrangement of the muscle groups and suggests a contribution to their commonly observed activation patterns.
doi:10.1007/s00221-012-3032-9
PMCID: PMC3324696  PMID: 22349561
Stretch reflex; Paraspinal muscles; Crossed reflex
11.  Kinematic Description of Elite Vs. Low Level Players in Team-Handball Jump Throw 
The jump throw is the most applied throwing technique in team- handball (Wagner et al., 2008); however, a comprehensive analysis of 3D-kinematics of the team-handball jump throw is lacking. Therefore, the purpose of our study was: 1) to measure differences in ball release speed in team- handball jump throw and anthropometric parameters between groups of different levels of performance and (2) to analyze upper body 3D-kinematics (flexion/extension and rotation) to determine significant differences between these groups. Three-dimensional kinematic data was analyzed via the Vicon MX 13 motion capturing system (Vicon Peak, Oxford, UK) from 26 male team-handball players of different performance levels (mean age: 21.2 ± 5.0 years). The participants were instructed to throw the ball (IHF Size 3) onto a target at 8 m distance, and to hit the center of a square of 1 × 1 m at about eye level (1.75 m), with maximum ball release speed. Significant differences between elite vs. low level players were found in the ball release speed (p < 0.001), body height (p < 0.05), body weight (p < 0.05), maximal trunk internal rotation (p < 0.05), trunk flexion (p < 0.01) and forearm pronation (p < 0.05) as well as trunk flexion (p < 0.05) and shoulder internal rotation (p < 0.001) angular velocity at ball release. Results of our study suggest that team-handball players who were taller and of greater body weight have the ability to achieve a higher ball release speed in the jump throw, and that an increase in trunk flexion and rotation angular velocity improve the performance in team-handball jump throw that should result in an increase of ball release speed.
Key pointsTeam-handball players who were taller and of greater body weight have the ability to achieve a higher ball release speed.An increase in trunk flexion, trunk rotation and shoulder internal rotation angular velocity should result in an increase of ball release speed.Trunk movements are normally well observable for experienced coaches, easy correctable and therefore practical to improve the performance in team-handball jump throw of low level players during training without using complex measurement devices.
PMCID: PMC3737958  PMID: 24149381
3D-kinematics; angular velocity; ball throwing technique; ball release speed.
12.  Short term modulation of trunk neuromuscular responses following spinal manipulation: a control group study 
Background
Low back pain (LBP) is one of the most frequent musculoskeletal conditions in industrialized countries and its economic impact is important. Spinal manipulation therapy (SMT) is believed to be a valid approach in the treatment of both acute and chronic LBP. It has also been shown that SMT can modulate the electromyographic (EMG) activity of the paraspinal muscle. The purpose of this study was to investigate, in a group of patients with low back pain, the persistence of changes observed in trunk neuromuscular responses after a spinal manipulation (SMT).
Methods
Sixty adult participants with LBP performed a block of 5 flexion-extension movements. Participants in the experimental group (n=30) received lumbar SMT whereas participants in the control group (n=30) were positioned similarly for the treatment but did not receive SMT. Blocks of flexion-extension movements were repeated immediately after the manipulation as well as 5 and 30 minutes after SMT (or control position). EMG activity of paraspinal muscles was recorded at L2 and L5 level and kinematic data were collected to evaluate the lumbo-pelvic kinematics. Pain intensity was noted after each block. Normalized EMG, pain intensity and lumbo-pelvic kinematics were compared across experimental conditions.
Results
Participants from the control group showed a significant increase in EMG activity during the last block (30 min) of flexion-extension trials in both flexion and full-flexion phases at L2. Increase in VAS scores was also observed in the last 2 blocks (5 min and 30 min) in the control group. No significant group x time interaction was seen at L5. No significant difference was observed in the lumbo-pelvic kinematics.
Conclusion
Changes in trunk neuromuscular control following HVLA spinal manipulation may reduce sensitization or muscle fatigue effects related to repetitive movement. Future studies should investigate short term changes in neuromuscular components, tissue properties and clinical outcomes.
doi:10.1186/1471-2474-14-92
PMCID: PMC3602072  PMID: 23496876
Spinal manipulation; Electromyography; Kinematics; Flexion-relaxation phenomenon
13.  Precision of estimates of local stability of repetitive trunk movements 
European Spine Journal  2013;22(12):2678-2685.
Purpose
Local dynamic stability of trunk movements quantified by means of the maximum Lyapunov exponent (λmax) can provide information on trunk motor control and might offer a measure of trunk control in low-back pain patients. It is unknown how many repetitions are necessary to obtain sufficiently precise estimates of λmax and whether fatigue effects on λmax can be avoided while increasing the number of repetitions.
Method
Ten healthy subjects performed 100 repetitions of trunk movements in flexion, of trunk rotation and of a task combining these movement directions. λmax was calculated from thorax, pelvis and trunk (thorax relative to pelvis) kinematics. Data series were analyzed using a bootstrap procedure; ICC and coefficient of variation were used to quantify precision as a function of the number of cycles analyzed. ANOVA was used to compare movement tasks and to test for effects of time.
Results
Trunk local stability reached acceptable precision level after 30 repetitions. λmax was higher (indicating lower stability) in flexion, compared to rotation and combined tasks. There was no time effect (fatigue). λmax of trunk movement was lower and less variable than that of thorax and pelvis movements.
Conclusions
The data provided allow for an informed choice of the number of repetitions in assessing local dynamic stability of trunk movements, weighting the gain in precision against the increase in measurement effort. Within the 100 repetitions tested, fatigue did not affect results. We suggest that increased stability during asymmetric movement may be explained by higher co-activation of trunk muscles.
doi:10.1007/s00586-013-2797-2
PMCID: PMC3843800  PMID: 23653131
Trunk; Spinal stability; Lyapunov exponent; Statistical precision
14.  Ankle Bracing, Plantar-Flexion Angle, and Ankle Muscle Latencies During Inversion Stress in Healthy Participants 
Journal of Athletic Training  2008;43(1):37-43.
Context: Ankle braces may enhance ankle joint proprioception, which in turn may affect reflexive ankle muscle activity during a perturbation. Despite the common occurrence of plantar-flexion inversion ankle injuries, authors of previous studies of ankle muscle latencies have focused on inversion stresses only.
Objective: To examine the latency of the peroneus longus (PL), peroneus brevis (PB), and tibialis anterior (TA) muscles in response to various degrees of combined plantar-flexion and inversion stresses in braced and unbraced asymptomatic ankles.
Design: Repeated measures.
Setting: University biomechanics laboratory.
Patients or Other Participants: Twenty-eight healthy females and 12 healthy males (n = 40: mean age = 23.63 years, range = 19 to 30 years; height = 172.75 ± 7.96 cm; mass = 65.53 ± 12.0 kg).
Intervention(s): Participants were tested under 2 conditions: wearing and not wearing an Active Ankle T1 brace while dropping from a custom-made platform into 10°, 20°, and 30° of plantar flexion and 30° of inversion.
Main Outcome Measure(s): The time between platform drop and the onset of PL, PB, and TA electromyographic activity was measured to determine latencies. We calculated a series of 2-way analyses of variance to determine if latencies were different between the conditions (braced and unbraced) and among the plantar-flexion angles (α = .05).
Results: No interaction was found between condition and plantar-flexion angle. No significant main effects were found for condition or plantar-flexion angle. Overall means for braced and unbraced conditions were not significantly different for each muscle tested. Overall means for angle for the PL, PB, and TA were not significantly different.
Conclusions: Reflexive activity of the PL, PB, or TA was unaffected by the amount of plantar flexion or by wearing an Active Ankle T1 brace during an unanticipated plantar-flexion inversion perturbation.
PMCID: PMC2231395  PMID: 18335011
ankle injuries; lower extremity; biomechanics; orthoses; reaction time
15.  Assessment of Isometric Trunk Strength – The Relevance of Body Position and Relationship between Planes of Movement 
The aim of the study was to assess the differences in maximal isometric trunk extension and flexion strength during standing, sitting and kneeling. Additionally, we were interested in correlations between the maximal strength in sagittal, frontal and transverse plane, measured in the sitting position. Sixty healthy subjects (24 male, 36 female; age 41.3 ± 15.1 yrs; body height 1.70 ± 0.09 m; body mass 72.7 ± 13.3 kg) performed maximal voluntary isometric contractions of the trunk flexor and extensor muscles in standing, sitting and kneeling position. The subjects also performed lateral flexions and rotations in the sitting position. Each task was repeated three times and average of maximal forces was used for data analysis. RANOVA with post-hoc testing was applied to the flexion and extension data. The level of statistical significance was set to p < 0.05. Overall, in both genders together, the highest average force for trunk extension was recorded in sitting posture (910.5 ± 271.5 N), followed by kneeling (834.3 ± 242.9 N) and standing (504.0 ± 165.4 N), compared with flexion, where we observed the opposite trend (508.5 ± 213.0 N, 450.9 ± 165.7 N and 443.4 ± 153.1 N, respectively). Post-hoc tests showed significant differences in all extension positions (p < 0.0001) and between sitting/standing (p = 0.018) and kneeling/standing (p = 0.033) flexion exertions. The extension/flexion ratio for sitting was 2.1 ± 0.4, for kneeling 1.9 ± 0.4, followed by standing, where motion forward approximately equals motion backward (1.1 ± 0.6). Trunk sagittal-transverse strength showed the strongest correlation, followed by frontal-transverse and sagittal-frontal plane correlation pairs (R2 = 0.830, 0.712 and 0.657). The baseline trunk isometric strength data provided by this study should help further strength diagnostics, more precisely, the prevention of low back disorders.
Key pointsMaximal voluntary isometric force of the trunk extensors increased with the angle at the hips (highest in sitting, medium in kneeling and lowest in upright standing).The opposite trend was true for isometric MVC force of trunk flexors (both genders together and men only).In the sitting position, the strongest correlation between MVC forces was found between sagittal (average flexion/extension) and transverse plane (average left/right rotation).In order to increase the validity of trunk strength testing the letter should include: specific warm-up, good pelvic fixation and visual feedback.
PMCID: PMC3990891  PMID: 24790491
Voluntary force; testing; hip angle; low back pain
16.  Reduced Quadriceps Activation After Lumbar Paraspinal Fatiguing Exercise 
Journal of Athletic Training  2006;41(1):79-86.
Context: Although poor paraspinal muscle endurance has been associated with less quadriceps activation (QA) in persons with a history of low back pain, no authors have addressed the acute neuromuscular response after lumbar paraspinal fatiguing exercise.
Objective: To compare QA after lumbar paraspinal fatiguing exercise in healthy individuals and those with a history of low back pain.
Design: A 2 × 4 repeated-measures, time-series design.
Setting: Exercise and Sport Injury Laboratory.
Patients or Other Participants: Sixteen volunteers participated (9 males, 7 females; 8 controls and 8 with a history of low back pain; age = 24.1 ± 3.1 years, height = 173.4 ± 7.1 cm, mass = 72.4 ± 12.1 kg).
Intervention(s): Subjects performed 3 sets of isometric lumbar paraspinal fatiguing muscle contractions. Exercise sets continued until the desired shift in lumbar paraspinal electromyographic median power frequency was observed. Baseline QA was compared with QA after each exercise set.
Main Outcome Measure(s): An electric burst was superimposed while subjects performed a maximal quadriceps contraction. We used the central activation ratio to calculate QA = (FMVIC/[FMVIC + FBurst])* 100, where F = force and MVIC = maximal voluntary isometric contractions. Quadriceps electromyographic activity was collected at the same time as QA measurements to permit calculation of median frequency during MVIC.
Results: Average QA decreased from baseline (87.4% ± 8.2%) after the first (84.5% ± 10.5%), second (81.4% ± 11.0%), and third (78.2% ± 12.7%) fatiguing exercise sets. On average, the group with a history of low back pain showed significantly more QA than controls. No significant change in quadriceps median frequency was noted during the quadriceps MVICs.
Conclusions: The quadriceps muscle group was inhibited after lumbar paraspinal fatiguing exercise in the absence of quadriceps fatigue. This effect may be different for people with a history of low back pain compared with healthy controls.
PMCID: PMC1421484  PMID: 16619099
superimposed burst technique; quadriceps muscle inhibition; low back pain
17.  Trunk Muscle Reflex Amplitudes Increased in Patients With Subacute, Recurrent LBP Treated With a 10-Week Stabilization Exercise Program 
Motor control  2012;17(1):1-17.
Altered trunk muscle reflexes have been observed in patients with low back pain (LBP). Altered reflexes may contribute to impaired postural control, and possibly recurrence of LBP. Specific stabilization exercise (SSE) programs have been shown to decrease the risk of LBP recurrence in a select group of patients with acute, first episode LBP. It is not known if trunk muscle reflex responses improve with resolution of subacute, recurrent LBP when treated with a SSE program. A perturbation test was used to compare trunk muscle reflexes in patients with subacute, recurrent LBP, before and after 10 weeks of a SSE program and a group of matched control subjects (CNTL). The LBP group pre therapy had delayed trunk muscle reflexes compared with the CNTL group. Post therapy reflex latencies remained delayed, but amplitudes increased. Increased reflex amplitudes could limit excessive movement of the spine when perturbed; potentially helping prevent recurrence.
PMCID: PMC3881973  PMID: 22964879
stabilization exercise; low back pain; sudden loading; reflex amplitude; multifidus
18.  Neuromuscular Response Characteristics in Men and Women After Knee Perturbation in a Single-Leg, Weight-Bearing Stance 
Journal of Athletic Training  2001;36(1):37-43.
Objective:
We examined whether muscle response times and activation patterns in the lower extremity differed between men and women in response to a rotational knee perturbation while standing in a single-leg, weight-bearing stance.
Design and Setting:
We used a lower extremity perturbation device to produce a sudden, forward, and either internal or external rotation moment of the trunk and femur relative to the weight-bearing tibia. Subjects completed 10 trials of both internal and external rotation perturbation; the first 5 acceptable trials were averaged and used for data analysis. Two separate, repeated-measures analyses of variance were used to compare myoelectric response times and activation patterns between men and women for both internal and external rotation perturbation.
Subjects:
Thirty-two female (19 lacrosse, 13 soccer) and 32 male (lacrosse) healthy intercollegiate athletes participated in the study.
Measurements:
We used surface electromyography to record long latency reflex times of the medial and lateral quadriceps, hamstring, and gastrocnemius muscles.
Results:
Women responded faster than men, primarily due to a shorter latency in quadriceps activation. However, men and women exhibited no difference in muscle-recruitment order.
Conclusions:
Although men and women demonstrated similar muscle-recruitment patterns to an imposed lower extremity perturbation, women tended to activate their quadriceps earlier than men. Whether this earlier quadriceps activation diminishes the ability of the hamstrings to adequately stabilize the knee joint or subjects the anterior cruciate ligament to greater risk of injury is still unknown and requires further study. Furthermore, although surface electromyography and measurement of myoelectric response times are useful in evaluating the timing, activation order, and coactivity patterns of the knee musculature, future studies should evaluate sex differences across the complete response continuum, including measures of intrinsic muscle stiffness, electromechanical delay, and time to force production.
PMCID: PMC155400  PMID: 12937513
electromyography; long latency reflex; anterior cruciate ligament
19.  Reduced thoracolumbar fascia shear strain in human chronic low back pain 
Background
The role played by the thoracolumbar fascia in chronic low back pain (LBP) is poorly understood. The thoracolumbar fascia is composed of dense connective tissue layers separated by layers of loose connective tissue that normally allow the dense layers to glide past one another during trunk motion. The goal of this study was to quantify shear plane motion within the thoracolumbar fascia using ultrasound elasticity imaging in human subjects with and without chronic low back pain (LBP).
Methods
We tested 121 human subjects, 50 without LBP and 71 with LBP of greater than 12 months duration. In each subject, an ultrasound cine-recording was acquired on the right and left sides of the back during passive trunk flexion using a motorized articulated table with the hinge point of the table at L4-5 and the ultrasound probe located longitudinally 2 cm lateral to the midline at the level of the L2-3 interspace. Tissue displacement within the thoracolumbar fascia was calculated using cross correlation techniques and shear strain was derived from this displacement data. Additional measures included standard range of motion and physical performance evaluations as well as ultrasound measurement of perimuscular connective tissue thickness and echogenicity.
Results
Thoracolumbar fascia shear strain was reduced in the LBP group compared with the No-LBP group (56.4% ± 3.1% vs. 70.2% ± 3.6% respectively, p < .01). There was no evidence that this difference was sex-specific (group by sex interaction p = .09), although overall, males had significantly lower shear strain than females (p = .02). Significant correlations were found in male subjects between thoracolumbar fascia shear strain and the following variables: perimuscular connective tissue thickness (r = -0.45, p <.001), echogenicity (r = -0.28, p < .05), trunk flexion range of motion (r = 0.36, p < .01), trunk extension range of motion (r = 0.41, p < .01), repeated forward bend task duration (r = -0.54, p < .0001) and repeated sit-to-stand task duration (r = -0.45, p < .001).
Conclusion
Thoracolumbar fascia shear strain was ~20% lower in human subjects with chronic low back pain. This reduction of shear plane motion may be due to abnormal trunk movement patterns and/or intrinsic connective tissue pathology. There appears to be some sex-related differences in thoracolumbar fascia shear strain that may also play a role in altered connective tissue function.
doi:10.1186/1471-2474-12-203
PMCID: PMC3189915  PMID: 21929806
20.  Neuromuscular adaptations after a rehabilitation program in patients with chronic low back pain: case series (uncontrolled longitudinal study) 
Background
To investigate the impact of a short-term multimodal rehabilitation program for patients with low back pain (LBP) on trunk muscle reflex responses and feedforward activation induced by postural perturbations.
Methods
Case series (uncontrolled longitudinal study). Thirty chronic patients with LBP (21 women and 19 men, mean age 42.6 ± 8.6 years, mean weight 73 ± 14 kg, mean height 174 ± 10 cm) were included. The intervention consisted in a 5-day program including therapeutic education sessions (360 min), supervised abdominal and back muscle strength exercises (240 min), general aerobic training (150 min), stretching (150 min), postural education (150 min) and aqua therapy (150 min). Feedforward activation level and reflex amplitude determined by surface electromyographic activity triggered by postural perturbations were recorded from abdominal and paraspinal muscles in unexpected and expected conditions. Subjects were tested before, just after and again one month after the rehabilitation program.
Results
No main intervention effect was found on feedforward activation levels and reflex amplitudes underlining the absence of changes in the way patients with LBP reacted across perturbation conditions. However, we observed a shift in the behavioral strategy between conditions, in fact feedforward activation (similar in both conditions before the program) decreased in the unexpected condition after the program, whereas reflex amplitudes became similar in both conditions.
Conclusions
The results suggest that a short-term rehabilitation program modifies trunk behavioral strategies during postural perturbations. These results can be useful to clinicians for explaining to patients how to adapt to daily life activities before and after rehabilitation.
doi:10.1186/1471-2474-14-277
PMCID: PMC3849067  PMID: 24063646
Low back pain; Rehabilitation; Electromyography; Motor skills; Postural perturbation
21.  RESPONSE OF LUMBAR PARASPINAL MUSCLES SPINDLES IS GREATER TO SPINAL MANIPULATIVE LOADING COMPARED WITH SLOWER LOADING UNDER LENGTH CONTROL 
Background Context
Spinal manipulation (SM) is a form of manual therapy used clinically to treat patients with low back and neck pain. The most common form of this maneuver is characterized as a high velocity (duration < 150ms), low amplitude (segmental translation < 2mm, rotation < 4°, and applied force 220-889N) impulse thrust (HVLA-SM). Clinical skill in applying an HVLA-SM lies in the practitioner's ability to control the duration and magnitude of the load (i.e., the rate of loading), the direction in which the load is applied, and the contact point at which the load is applied. Control over its mechanical delivery presumably related to its clinical effects. Biomechanical changes evoked by an HVLA-SM are thought to have physiological consequences caused, at least in part, by changes in sensory signaling from paraspinal tissues.
Purpose
If activation of afferent pathways does contribute to the effects of an HVLA-SM, it seems reasonable to anticipate that neural discharge might increase or decrease in a non-linear fashion as the thrust duration thrust approaches a threshold value. We hypothesized that the relationship between the duration of an impulsive thrust to a vertebra and paraspinal muscle spindle discharge would be non-linear with an inflection near the duration of an HVLA-SM delivered clinically (<150ms). In addition, we anticipated that muscle spindle discharge would be more sensitive to larger amplitude thrusts.
Study Design/Setting
A neurophysiological study of spinal manipulation using the lumbar spine of a feline model.
Methods
Impulse thrusts (duration: 12.5, 25, 50, 100, 200, and 400 ms; amplitude 1 or 2mm posterior to anterior) were applied to the spinous process of the L6 vertebra of deeply anesthetized cats while recording single unit activity from dorsal root filaments of muscle spindle afferents innervating the lumbar paraspinal muscles. A feedback motor was used in displacement control mode to deliver the impulse thrusts. The motor's drive arm was securely attached to the L6 spinous process via a forceps.
Results
As thrust duration became shorter the discharge of the lumbar paraspinal muscle spindles increased in a curvilinear fashion. A concave up inflection occurred near the 100ms duration eliciting both a higher frequency discharge compared to the longer durations and a substantially faster rate of change as thrust duration was shortened. This pattern was evident in paraspinal afferents with receptive fields both close and far from the midline. Paradoxically, spindle afferents were almost twice as sensitive to the 1mm compared to the 2mm amplitude thrust (6.2 vs 3.3 spikes/s/mm/s). This latter finding may be related to the small vs large signal range properties of muscle spindles.
Conclusions
. The results indicate that the duration and amplitude of a spinal manipulation elicits a pattern of discharge from paraspinal muscle spindles different from slower mechanical inputs. Clinically, these parameters may be important determinants of an HVLA-SM's therapeutic benefit.
doi:10.1016/j.spinee.2006.10.006
PMCID: PMC2075482  PMID: 17905321
lumbar spine; spinal manipulation; chiropractic; osteopathy; paraspinal muscles; muscle spindle
22.  Trunk stiffness and dynamics during active extension exertions 
Journal of biomechanics  2005;38(10):2000-2007.
Spinal stability is related to the recruitment and control of active muscle stiffness. Stochastic system identification techniques were used to calculate the effective stiffness and dynamics of the trunk during active trunk extension exertions. Twenty-one healthy adult subjects (10 males, 11 females) wore a harness with a cable attached to a servomotor such that isotonic flexion preloads of 100, 135, and 170 N were applied at the T10 level of the trunk. A pseudorandom stochastic force sequence (bandwidth 0–10 Hz, amplitude ±30 N) was superimposed on the preload causing small amplitude trunk movements. Nonparametric impulse response functions of trunk dynamics were computed and revealed that the system exhibited underdamped second-order behavior. Second-order trunk dynamics were determined by calculating the best least-squares fit to the IRF. The quality of the model was quantified by comparing estimated and observed displacement variance accounted for (VAF), and quality of the second-order fits was calculated as a percentage and referred to as fit accuracy. Mean VAF and fit accuracy were 87.8 ± 4.0% and 96.0 ± 4.3%; respectively, indicating that the model accurately represented active trunk kinematic response. The accuracy of the kinematic representation was not influenced by preload or gender. Mean effective stiffness was 2.78 ± 0.96 N/mm and increased significantly with preload (p< 0.001), but did not vary with gender (p = 0.425). Mean effective damping was 314 ± 72 N s/m and effective trunk mass was 37.0 ± 9.3 kg. We conclude that stochastic system identification techniques should be used to calculate effective trunk stiffness and dynamics.
doi:10.1016/j.jbiomech.2004.09.014
PMCID: PMC1630678  PMID: 16084200
Low back; Dynamics; Stiffness; Model
23.  Altered Timing of Postural Reflexes Contributes to Falling in Persons with Chronic Stroke 
The purpose of this study was to determine differences in the timing of postural reflexes and changes in kinematics between those who fell (Fallers) in response to standing platform translations and those who did not (Non-fallers). Forty-four persons with stroke were exposed to unexpected forward and backward platform translations while standing. Surface electromyography from bilateral tibialis anterior, gastrocnemius, rectus femoris, and biceps femoris were recorded along with kinematic data. Those that fell in response to the translations were compared to those who did not fall in terms of (1) postural reflex onset latency, (2) the time interval between the activation of distal and proximal muscles (i.e. intralimb coupling), and (3) changes in joint angles and trunk motion. Approximately 85% of falls occurred in response to the forward translations. Postural reflex onset latencies were delayed and intralimb coupling durations were longer in the Faller versus Non-faller group. At the time that the platform completed the translating motion (300 ms), the Faller group demonstrated higher trunk velocity, greater change in paretic ankle angle, and the trunk was further behind the ankle compared to the Non-faller group. This study suggests that following platform translations, delays in the timing of postural reflexes and disturbed intralimb coupling result in changes in kinematics, which contribute to falls in persons with stroke.
doi:10.1007/s00221-005-0293-6
PMCID: PMC3226801  PMID: 16418855 CAMSID: cams1999
falls; cerebrovascular accident; reflex; perturbation; postural control
24.  Lower trunk kinematics and muscle activity during different types of tennis serves 
Background
To better understand the underlying mechanisms involved in trunk motion during a tennis serve, this study aimed to examine the (1) relative motion of the middle and lower trunk and (2) lower trunk muscle activity during three different types of tennis serves - flat, topspin, and slice.
Methods
Tennis serves performed by 11 advanced (AV) and 8 advanced intermediate (AI) male tennis players were videorecorded with markers placed on the back of the subject used to estimate the anatomical joint (AJ) angles between the middle and lower trunk for four trunk motions (extension, left lateral flexion, and left and right twisting). Surface electromyographic (EMG) techniques were used to monitor the left and right rectus abdominis (LRA and RRA), external oblique (LEO and REO), internal oblique (LIO and RIO), and erector spinae (LES and RES). The maximal AJ angles for different trunk motions during a serve and the average EMG levels for different muscles during different phases (ascending and descending windup, acceleration, and follow-through) of a tennis serve were evaluated.
Results
The repeated measures Skill × Serve Type × Trunk Motion ANOVA for maximal AJ angle indicated no significant main effects for serve type or skill level. However, the AV group had significantly smaller extension (p = 0.018) and greater left lateral flexion (p = 0.038) angles than the AI group. The repeated measures Skill × Serve Type × Phase MANOVA revealed significant phase main effects in all muscles (p < 0.001) and the average EMG of the AV group for LRA was significantly higher than that of the AI group (p = 0.008). All muscles showed their highest EMG values during the acceleration phase. LRA and LEO muscles also exhibited high activations during the descending windup phase, and RES muscle was very active during the follow-through phase.
Conclusion
Subjects in the AI group may be more susceptible to back injury than the AV group because of the significantly greater trunk hyperextension, and relatively large lumbar spinal loads are expected during the acceleration phase because of the hyperextension posture and profound front-back and bilateral co-activations in lower trunk muscles.
doi:10.1186/1758-2555-1-24
PMCID: PMC2770553  PMID: 19825184
25.  Sagittal-Plane Trunk Position, Landing Forces, and Quadriceps Electromyographic Activity 
Journal of Athletic Training  2009;44(2):174-179.
Context:
Researchers have suggested that large landing forces, excessive quadriceps activity, and an erect posture during landing are risk factors for anterior cruciate ligament (ACL) injury. The influence of knee kinematics on these risk factors has been investigated extensively, but trunk positioning has received little attention.
Objective:
To determine the effect of trunk flexion on landing forces and quadriceps activation during landing.
Design:
Two (sex) × 2 (task) repeated-measures design.
Setting:
Research laboratory.
Patients or Other Participants:
Forty healthy, physically active volunteers (20 men, 20 women).
Intervention(s):
Participants performed 2 drop-landing tasks. The first task represented the natural, or preferred, landing strategy. The second task was identical to the first except that participants flexed the trunk during landing.
Main Outcome Measure(s):
We measured peak vertical and posterior ground reaction forces and mean quadriceps electromyographic amplitude during the loading phase of landing (ie, the interval from initial ground contact to peak knee flexion).
Results:
Trunk flexion decreased the vertical ground reaction force (P < .001) and quadriceps electromyographic amplitude (P < .001). The effect of trunk flexion did not differ across sex for landing forces or quadriceps electromyographic activity.
Conclusions:
We found that trunk flexion during landing reduced landing forces and quadriceps activity, thus potentially reducing the force imparted to the ACL. Research has indicated that trunk flexion during landing also increases knee and hip flexion, resulting in a less erect landing posture. In combination, these findings support emphasis on trunk flexion during landing as part of ACL injury-prevention programs.
PMCID: PMC2657019  PMID: 19295962
anterior cruciate ligament; ground reaction forces; injury prevention; risk factors

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