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T
he definition of spine instability6,72 and its clinical relevance52,81 from studying the concepts of stability
have been debated over several decades. The changing nature and the potential for future progress in
of this debate appears to reflect an evolution of concepts, which pursuit of understanding the etiology of
back pain. The focus of the commentary
is propelled by our improved understanding of spine function
is on lumbar spine stability, but similar
and back pain in parallel with our improved understanding of stability. concepts could be applied when studying
This commentary provides a broad def- difficult to directly observe) spine system other forms of back pain, such as those
inition of stability, which is later used to and discuss recent scientific and techno- involving the sacroiliac joints/pelvic gir-
demonstrate how various interpretations logical advances that underpin improved dle. Finally, although not the main focus
of “spine stability” can be integrated into access. Finally, we speculate on a possible of this paper, interdisciplinary integra-
a unifying framework. Next, we examine next step in the evolution of the concept of tion of knowledge using a systems-based
basic and clinical evidence supporting or stability, which further broadens the inter- approach is showcased using spine stabil-
refuting the presence of spine instability pretation to include nonmechanical issues ity as an example.
and its potential link to back pain. We go involved in the experience of pain.
on to highlight challenges with inferring The overall goal of this commentary is Defining Stability
instability in a complex, inaccessible (ie, to showcase the critical knowledge gained In general terms, stability is tested by ap-
plying a small perturbation to a system
UUSYNOPSIS: Individuals with back pain are ever, this neural and mechanical coupling could be of interest and observing the new behav-
often diagnosed with spine instability, even though problematic in an injured spine. Finally, instability ior.90 If the new behavior is approximately
it is unclear whether the spine is susceptible to traditionally contemplated from a mechanical and the same as the old, then the system is
unstable behavior. The spine is a complex system control perspective could potentially be applied
stable (eg, a ball in a valley returning
with many elements that cannot be directly to study processes involved in pain sensitization,
and possibly back pain that is iatrogenic in nature. to the undisturbed position). If the dis-
observed, which makes the study of spine function
and direct assessment of spine instability difficult. This commentary argues for a more contemporary turbed behavior differs significantly from
What is known is that trunk muscle activation and broadened view of stability that integrates the old behavior, then the system is un-
is adjusted to meet stability demands, which interdisciplinary knowledge in order to capture stable (eg, a ball on a hill rolling away fol-
highlights that the central nervous system closely the complexity of back pain. J Orthop Sports
lowing a perturbation).
monitors threats to spine stability. The spine Phys Ther 2019;49(6):415-424. Epub 25 Apr 2019.
doi:10.2519/jospt.2019.8144 This broad definition of stability pro-
appears to be protected by neural coupling and
UUKEY WORDS: iatrogenic back pain, lumbar spine
vides the framework to discuss stability
mechanical coupling that prevent erroneous motor
control from producing segmental instability; how- stability, pain sensitization, systems-based approach in different contexts, including “mechani-
cal” stability and “control” stability. But
1
Center for Orthopedic Research, Michigan State University, Lansing, MI. 2Department of Osteopathic Surgical Specialties, Michigan State University, East Lansing, MI. 3Sumaq
Life LLC, East Lansing, MI. 4Department of Human Movement Sciences, Vrije Universiteit Amsterdam and Amsterdam Movement Sciences, Amsterdam, the Netherlands.
5
Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada. 6Clinical Centre for Research Excellence in Spinal Pain, Injury and
Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia. Dr Reeves is the founder and president of Sumaq Life LLC. Dr Hodges
receives book royalties from Elsevier. Professional and scientific bodies have reimbursed him for travel costs related to presentation of research on pain, motor control, and
exercise therapy at scientific conferences/symposia. He has received fees for teaching practical courses on motor control training. He is also supported by a Senior Principal
Research Fellowship from the National Health and Medical Research Council of Australia (APP1102905). The other authors certify that they have no affiliations with or financial
involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr N. Peter Reeves,
712 Audubon Road, East Lansing, MI 48823. E-mail: reevesn@icloud.com t Copyright ©2019 Journal of Orthopaedic & Sports Physical Therapy®
+
commands position
Spine tive and complete understanding of sys-
tem behavior.
+ Gravity From a clinical perspective, this may
explain the absence of one-to-one map-
– Stiffness
(osteoligamentous)
ping between degenerative spine changes,
which can alter spine stiffness and affect
– Stiffness stability,66 and back pain.48 One could
(muscles) argue that medical diagnosis of degen-
erative spine changes is insufficient in
Spine with muscles
the assessment of back pain, and that the
quality of trunk muscle control must also
FIGURE 2. In this context, the system of interest is the spine with muscles. This static mechanical characterization
of the spine does not include any neural control at this point. Gravitational forces can be represented mathematically be considered,78 as this may (or may not)
as positive feedback, whereas stiffness from passive tissue and muscle activation can be represented as negative be sufficient to compensate for the impact
feedback. If muscle activation is sufficient, the negative feedback influences overcome the positive feedback of degeneration.78,79 Likewise, joint laxity
influences, producing a spine system with overall negative feedback, making the spine stable. Abbreviation: CNS, or hypermobility, without consideration of
central nervous system.
muscle control, will fail to represent the
+
CNS Tissue damage Noxious afferents adaptation to address mechanical and
Nociceptors
neural deficits that threaten spine sta-
Noxious afferent
Perception of pain
+
the pain disorder (see O’Sullivan76 for
(eg, unpleasant Spinal neurons
experience) a case study). A positive feedback loop
may be created when individuals believe
Chemical release + their spine is vulnerable to instability
(glutamate)
Analgesic therapies and react to this threat by protecting
(eg, TENS, opioid – their spine through excessive coactiva-
peptides)
tion, such that it exceeds the demands
Perception of pain for stabilization, which causes pain that
then reinforces the notion that the spine
FIGURE 4. Expansion of the concept of stability to integrate neural processes involved in the experience of is vulnerable (see FIGURE 5). At present,
pain. In this new subsystem, which represents a simple model of nociceptive/pain pathways, there are positive
there is some limited research to support
feedback influences producing pain sensitization as well as negative feedback influences reducing nociceptive
neuron discharge (ie, when you feel pain, you use analgesic therapies). The goal for the research community is to
this hypothesis. For example, back pain
systematically identify these influences so that targeted treatment can be applied to minimize positive feedback interventions that include education
pathways and/or accentuate negative feedback influences. The objective of the overall system is to have a surplus that the spine is a highly robust struc-
of negative feedback to control pain. Abbreviations: ACh, acetylcholine; CNS, central nervous system; TENS, ture have some evidence of efficacy.84
transcutaneous electrical nerve stimulation.
Given the potential for an iatrogenic
T
o conclude, we return to the demands for maintaining stability, which must be thoughtfully posed to the general
title of this paper, “Are Stability and could underpin development of pain and public to avoid maladaptive strategies in
Instability Relevant Concepts for injury secondary to fatigue or increased those individuals who would otherwise
Back Pain?” As expressed here, our un- tissue loading. be healthy and productive.
derstanding of spine stability has evolved New scientific and technical advances Finally, the systems-based framework
over time and continues to evolve. Knowl- that help access variables of interest and used in this commentary has the poten-
edge gained related to spine function and define elements of spine control, com- tial for interdisciplinary integration of
back pain is linked with advances in our bined with more comprehensive assess- knowledge, which is currently lacking
understanding of stability and instability, ment of spine control, will hopefully shed in the spine community. We use stabil-
making the terms very relevant. some additional light on the relevance of ity concepts to showcase the benefits of
We know that stability is also relevant instability. Future directions for research systems-based approaches in unifying the
to the central nervous system. Several could continue the expansion of the con- science surrounding the etiology of back
studies have shown that the central ner- cept of stability. This expansion might in- pain. Our understanding of back pain is
vous system carefully monitors stability clude adapting ideas used for controlling far from complete, but the framework
demands on the spine. We do not know mechanical variables (ie, spine kinemat- provides a means to move forward in a
whether the spine experiences unstable ics) to control neural signals representing rigorous and coherent way. t
behavior resulting in injury. Neural and nociceptive afferents and the perception
mechanical coupling reduces the risk of of pain, thus reflecting a broader perspec- ACKNOWLEDGMENTS: The forum on which this
instability in a healthy spine. However, tive on back pain. body of research was based, “State-of-the-
in an injured spine, joint laxity, neural As Bellman7 indicated in our opening Art in Motor Control and Low Back Pain:
inhibition, and reduced force-generating epigraph, instability is a weighty term International Clinical and Research Expert
capacity and endurance of muscles cre- not without history. Although speculative Forum,” was supported by the National
Health and Medical Research Council of
Australia, in collaboration with the North
It appears
American Spine Society. The forum was
you have an
Output
+ Input
unstable spine. chaired by Dr Paul Hodges.
Perception of pain Perception that the spine is fragile
CNS
interpretation Noxious
+ subsystem + afferent REFERENCES
CNS Spinal neurons
motor subsystem 1. Adams MA, Hutton WC. Prolapsed interverte-
subsystem bral disc: a hyperflexion injury. Spine (Phila Pa
+ + Noxious 1976). 1982;7:184-191. https://doi.org/10.1097%
afferent
+
Trunk muscle 2F00007632-198205000-00002
Spine
coactivation Nociceptor 2. Alaranta H, Tallroth K, Soukka A, Heliövaara M.
neuromuscular subsystem
subsystem Tissue Fat content of lumbar extensor muscles and low
damage
back disability: a radiographic and clinical com-
parison. J Spinal Disord. 1993;6:137-140.
Possible pathway for iatrogenic pain 3. Alqarni AM, Schneiders AG, Hendrick PA. Clinical
tests to diagnose lumbar segmental instabil-
ity: a systematic review. J Orthop Sports Phys
FIGURE 5. In this context, we expand the system to include a social factor that could influence back pain. In this Ther. 2011;41:130-140. https://doi.org/10.2519/
system, information from clinicians indicating that the spine is fragile represents input into the general population, jospt.2011.3457
which may result in some individuals changing their spine control strategy to a coactivation strategy that could 4. Anders C, Wagner H, Puta C, Grassme R, Petro-
lead to excessive tissue loading and damage. This could subsequently act as input into nociceptive/pain pathways vitch A, Scholle HC. Trunk muscle activation
(nociceptors, spinal neurons, and CNS interpretation subsystems). The output, the perception of pain, is then fed patterns during walking at different speeds. J
back to strengthen the perception that the spine is fragile. This, in turn, drives a positive feedback loop that creates Electromyogr Kinesiol. 2007;17:245-252. https://
back pain that is maintained by iatrogenic means. If iatrogenic maintenance of back pain exists, then one solution doi.org/10.1016/j.jelekin.2006.01.002
would be to change messaging to the general population, indicating that the spine is a highly robust structure. 5. Andreopoulou G, Maaswinkel E, Cofré Lizama LE,
Abbreviation: CNS, central nervous system. van Dieën JH. Effects of support surface stability
@ MORE INFORMATION
performance and spinal loading during a fatigu- analysis of the literature. J Electromyogr Kine-
ing isometric trunk extension with varying torque siol. 2003;13:333-351. https://doi.org/10.1016/
requirements. J Spinal Disord. 1997;10:145-156. S1050-6411(03)00041-5 WWW.JOSPT.ORG