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Are Stability and Instability Relevant Concepts for Back Pain?

Article  in  Journal of Orthopaedic and Sports Physical Therapy · April 2019

DOI: 10.2519/jospt.2019.8144

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 [ clinical commentary ]
N. PETER REEVES, PhD1-3 • JACEK CHOLEWICKI, PhD1,2  •  JAAP H. VAN DIEËN, PhD4
GREG KAWCHUK, PhD5  •  PAUL W. HODGES, PT, PhD, DSc, MedDr, BPhty (Hons)6

Are Stability and Instability

Relevant Concepts for Back Pain?
“Stability is a heavily loaded term with an unstable definition.”
— Richard Bellman7

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®

journal of orthopaedic & sports physical therapy | volume 49 | number 6 | june 2019 | 415

 [ clinical commentary ]
this broad definition also provides insight ball example in FIGURE 1). As we pro­gress Individual lumbar segments of the spine
into other contexts relevant to the mani- through different contexts of stability, we all must be stable to provide the neces-
festation of back pain. This definition highlight positive and negative feedback sary foundation for controlling the trunk.
may appear to be vague in nature, but it is effects on spine function and back pain.
derived from mathematical laws, making It is important to note that we in- Evolution in the Concepts of
it highly robust in its application. Within terchange the concepts of stability and Spine Stability and Instability
this formal theory, feedback is critical to instability throughout the paper. As sta- Early work has represented stability in
the mathematical determination of sta- bility and instability are dichotomous terms of a static mechanical concept (see
bility. Briefly, negative feedback stabi- terms,86,90 by defining one, we define the Reeves and Cholewicki85 for review) (FIGURE
lizes systems, whereas positive feedback other. Also, we shift between discussions 2). Briefly, weight from body mass acts to
destabilizes systems. To be stable, the of lumbar intersegmental stability and destabilize the spine (positive feedback),
contributions of all positive and negative trunk stability to accurately reflect the lit- whereas stiffness (negative feedback) from
feedback acting on the system must pro- erature. Essentially, lumbar intersegmen- passive tissue (eg, discs and ligaments) ex-
duce overall negative feedback (see the tal stability and trunk stability are linked. erts a stabilizing influence. Studies have
shown that the spine in a neutral posi-
tion has insufficient stiffness to counteract
Not stable Input Output upper-body mass; therefore, the upright
Ball perturbation Ball position
+ Ball spine is unstable and buckles under body
weight.21 Muscles that traverse the spine
+ (eg, paraspinal muscles) help stabilize it
Gravity by acting as variable-stiffness springs, with
Ball on hill
the level of stiffness increasing with activa-
tion.53 Above some nominal level of muscle
Stable Input Output
Ball perturbation Ball position activation (approximately 2% of maximum
+ Ball voluntary activation), there is sufficient
stiffness to support the upper body.18
– Gravity As a side note, the classification of
Ball in valley
stability depends on which system is be-
ing studied. As indicated above, a system
FIGURE 1. A ball on top of a hill is an example of a system with positive feedback. After applying a small
perturbation, gravitational forces act in the same direction of ball movement (positive feedback) to push representing a spine devoid of muscles is
the ball farther from its undisturbed position. Alternatively, a ball in a valley is an example of a system with unstable; however, if we expand the sys-
negative feedback. After applying the small perturbation, gravitational forces act in the opposite direction of ball tem to include trunk muscles, assuming
displacement to return the ball to its undisturbed position. sufficient levels of muscle activation, then
the spine becomes stable. As we capture
more components or subsystems of the
Input Output
CNS motor Spine system, we develop a more representa-

+
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

416 | june 2019 | volume 49 | number 6 | journal of orthopaedic & sports physical therapy

function of the system. In other words,
the complex spine system cannot be ac-
curately represented in diagnoses without
comprehensive analysis.
The next stage in the evolution of
the term spine stability involved a shift
from a static mechanical concept to a
dynamic control concept (see Reeves et
al90 for review) (FIGURE 3). The conceptual
framework was expanded to incorporate
the effects of sudden, unexpected loading
events believed to contribute to severe
back injuries,9,28,99 to explore the relation-
ship between delayed trunk muscle reflex
responses and back pain62,83,88 and future
back injuries,19 and the potential role of
modified preparatory trunk control in
advance of predictable spine perturba-
tions.46 The preceding static character-
ization of spine stability had shown the
magnitude of trunk muscle activity re-
quired to prevent the spine from buck-
ling, but it omitted an important aspect
of spine control, namely, timing of muscle
activation.
With this dynamic characterization of
stability, new spine models were created
that parsed the system into 2 compo-
nents: the spine/trunk, representing the
object to be controlled, and neurological
Input
CNS motor
+
commands
Afferent signals
Efferent signals
control, representing various sensorimo-
tor pathways necessary to ensure stable
spine behavior.26,30,33,89 Using this new
representation, it was discovered that
intrinsic mechanical stiffness from trunk
muscles is insufficient to support the
spine and that reflex contributions are
needed for stability.69 This work and that
of others16,106 supported the belief that
the spine is very close to the boundary
between stability and instability during
nonstrenuous activities and suggested
that neural control must be tightly regu-
lated to avoid instability.
Evidence to Support or Refute the Idea
That Spine Instability Causes Back Pain
There is strong evidence that the central
nervous system monitors spine stability,
although it remains unclear which sig-
nals/information are used to derive the
complex phenomenon. Modeling and
experimental results both demonstrate
that trunk muscles change activation
levels to meet stability demands, such as
holding a mass higher,32 adding weight to
the trunk,18 or lifting an unstable load,103
or when stability is threatened from im-
paired trunk control following a fatiguing
exertion,88,95 a loss of sensory informa-
Output
Spine position
Spine with
muscles
tion (eg, eyes closed),106 or when intrinsic
spine stiffness is reduced following pro-
longed periods of trunk flexion.109 Such
responses reflect a conscious, or perhaps
unconscious, concern with spine instabil-
ity, and that neuromuscular control may
be adapted to avoid it.
There are some anatomical features
that suggest that humans may have
evolved to protect the spine against insta-
bility. For example, early anatomical ob-
servations have shown neural coupling of
motor units in the spinal cord94 via long
spinal interneurons that function to co-
ordinate muscle activity.73 Axial muscles,
compared to more distal muscles, have
longer spinal interneurons, indicating
that trunk muscles tend to activate to-
gether, while distal muscles allow for
more independent control (eg, muscles
controlling the fingers).50
It is important to acknowledge that
although basic neural architecture may
be available to link activity at multiple
levels, this does not imply that trunk
muscles only act en masse. Independent
activation of trunk muscles has been
observed for a range of tasks.20,70,71 With
that said, trunk muscles are often inter-
connected through attachments to fascial
layers that span several spine segments61
and extramuscular fascia that create me-
chanical coupling between neighboring
muscles.55,56 As with neural coupling, me-
chanical coupling disperses force applied
to the spine, thus increasing control de-

+ Gravity pendence between segmental levels. This

neural and mechanical coupling suggests
– (osteoligamentous)
Stiffness
that recruitment of trunk muscles would
be less prone to an erroneous motor con-
– Stiffness
(muscles) trol signal that could result in segmental
instability; however, further work is re-
– Delay Neural control quired to determine the degree to which
these features impact function.
Spine neuromuscular system Although neural and mechanical cou-
pling mechanisms appear to be available
FIGURE 3. In this context, the system includes the spine with muscles (simplified in the figure) and with neural to protect a healthy spine, they may nega-
elements needed to dynamically control the spine. The literature indicates that when the spine is upright, the
passive stiffness from the osteoligamentous spine and muscles is insufficient for stability,69 reflecting an overall
tively impact control in an injured spine.
positive feedback system. Reflex contributions create a small but sufficient negative feedback loop, causing the First, joint laxity can occur with injury,77
entire system to become stable. Therefore, in the presence of a perturbation, the spine will maintain its original degenerative disc disease66,82 (although
behavior, which will return it to its undisturbed stationary position or some intended spine kinematic trajectory. not with more significant degenera-
Abbreviation: CNS, central nervous system.
tion29), and spondylolisthesis.34 As injury

journal of orthopaedic & sports physical therapy | volume 49 | number 6 | june 2019 | 417

 [ clinical commentary
and degenerative changes are not equally
present at all levels,1 this laxity may be iso-
lated to a single level, creating segmental
hypermobility.102 As highlighted above,
consideration of the passive laxity alone
does not imply instability; muscle control
must also be considered. Second, deeper
segmental muscles, like the multifidus,
are often atrophied in those with back
pain36,37 and in those with degenerative
lumbar spine pathology93 with evidence
of fibrosis43 and fatty infiltration.2,43 This
muscle wasting is believed to be related
to reflex inhibition following injury,39 at
least in the early period after injury.42
Neural inhibition could also delay
muscle activation at the affected level,
as has been observed.58 Both multifidus
atrophy and neural inhibition can be
problematic from a stability perspec-
tive. Large superficial muscles spanning
the lumbar spine add a compressive
load that acts to destabilize the spine,
much like gravity.31 Therefore, it is very
important that deeper muscles that
have attachments to specific spine lev-
els are recruited sufficiently to provide
the needed stiffness to prevent the spine
from buckling.8 Therefore, the ratio of
deep to superficial muscle activation
must be carefully controlled, as well as
the timing of activation, with the deeper
segmental muscles activating before
the more superficial muscles (see Mac-
Donald et al58,59 for evidence of deep-
to-superficial trunk muscle activation
patterns). Thus, joint hypermobility,
muscle wasting, and reflex inhibition in
deeper segmental muscles may act to-
gether to create inhomogeneity in both
the spine’s mechanical structure and its
control, which could have a destabilizing
influence on the spine.
Relatively straightforward solutions
to protect the spine from mechanical and
neural inhomogeneity are available. The
most basic, which has been alluded to pre-
viously, is that of increasing mechanical
stiffness via trunk muscle coactivation,53
which would obviate the need for reflex
responses96 or fine-tuned preparatory
activation. There is evidence to support
418 | june 2019 | volume 49 | number 6 | journal of orthopaedic & sports physical therapy
that some people with back pain protect
themselves using this coactivation strat-
egy,64,101,104 as do healthy individuals in re-
sponse to acute noxious input.41
Some additional coactivation can be
beneficial for patients with mechanical
and neural inhomogeneity, but addition-
al coactivation can also lead to pain and
tissue injury. For instance, contractions
sustained above 5% maximum voluntary
effort (and possibly as low as 2%) can lead
to muscle fatigue105 and pain.10,15,49 Nor-
mal daily activities use very little trunk
muscle activation,18 and such activation
appears to be below levels where muscles
become fatigued. With a threat of insta-
bility, some individuals may elevate trunk
muscle activation beyond the fatigue-free
range. Compounding the issue is that in-
dividuals with back pain have more of the
fatigable paraspinal muscle fiber types.63
Therefore, back pain may also be indi-
rectly linked to spine instability through
additional demands and reduced muscle
capacity, resulting in fatigue-related pain.
For patients with mechanical and neural
inhomogeneity, conditioning of paraspi-
nal muscles to improve fatigue resistance
may be a viable treatment objective.
There is mixed evidence from clinical
trials to support the connection between
spine instability and back pain. Pooled
analyses of clinical data revealed that, for
chronic back pain, specific stabilization
exercises are superior to usual medical
care and education, but not to manipu-
lative therapy,23 at least when the inter-
ventions are applied in a generic manner
without individual tailoring. No addition-
al effect was found when specific stabiliza-
tion exercise was added to a conventional
physical therapy program23 or other active
interventions.65,92 Some believe that these
clinical improvements are due to the posi-
tive effects of physical exercise rather than
to improvements in spinal stability.52 Gen-
eral exercises that condition muscles may
improve fatigue resistance in people with
back pain, which could explain why there
may not be significant differences between
specific stabilization exercises and other
active treatment programs.
]
An alternative interpretation of the
limited difference between efficacy of
different treatments is that most clinical
trials ignore the heterogeneity of back
pain presentation and assume that ev-
ery patient may benefit from an exercise
approach that aims to enhance stabiliza-
tion, with an identical treatment applied
to all patients. Even in the most opti-
mistic view, it would seem unlikely for
instability or even similar destabilizing
characteristics (eg, joint hypermobility,
muscle wasting, and reflex inhibition)
to underlie all back pain presentations.
Thus, it has been argued that larger ef-
fects may be apparent if intervention is
individualized for the presentation of
the patient and targeted to those who
present with the subtype of back pain
related to specific destabilizing influ-
ences. Although not all recent evidence
has supported this view (eg, outcomes
of stabilization programs for individu-
als who are expected to benefit and those
who are not were not different in 1 trial),
it is unclear whether the criteria used to
differentiate the groups relate to “insta-
bility.”35 In addition, some trials have not
changed attributes of underlying motor
control impairments,47 which may indi-
cate that the treatment was inadequate
to change the targeted feature.
New Methods to Assess Spine Stability
Spine function and back pain are chal-
lenging to study because we have limited
access to directly observe many features
of the spine and its behavior. For nonhu-
man systems such as automobiles and
aircraft, sensors can be placed through-
out the system to monitor variables im-
portant for stability and control. These
complex systems are accessible (observ-
able), which makes studying them less
challenging—but still challenging. The
spine has all the complexity of sophisti-
cated man-made machines, but without
the accessibility. However, there have
been scientific and technical advances
to improve access to the spine. These
advances include spinal imaging to as-
sess spine kinematics and systems-based
models to uncover elements respon-
sible for spine control. Although clinical
measures (eg, manual tests,3 question-
naires,60 radiography,97 and ultrasound
assessments100) have been developed and
advocated for assessment of instability,
the lack of a gold standard measure, and
the necessity to consider instability from
a multidimensional perspective, means
that their validity as tests of instability
remains unclear.
The inability to precisely measure
intervertebral motion is a major barrier
in spine research. Single-plane digital
videofluoroscopy has been used in the
past to study spine kinematics11,12,17,74 and
to document aberrant spine motion in
people with back pain,98 with findings
suggestive of impaired spine control and
possible instability. More recently, 2 digi-
tal videofluoroscopic systems were com-
bined to capture a more complete view of
spine kinematics.54,110,111 Dual videofluoro-
scopic systems improve spatial accuracy
(spine translation of less than 0.4 mm,
spine speed of 0.20 mm/s) and repeat-
ability (spine translation of less than 0.3
mm, spine rotation of less than 0.7°)110 by
taking advantage of irregularities in spine
shape to register 2 out-of-plane images.
Improved spatial resolution during spine
movement could improve clinical diag-
nosis by better describing the direction
of aberrant spine motion than is possible
with standard lateral flexion/extension
radiographs.22 Better clinical diagnosis
could improve clinical decision making
and lead to more personalized treatment
to correct aberrant spine motion. How-
ever, this is just one aspect of spine con-
trol that can be measured, and advances
in measures of the many other factors are
also required.
We cannot definitively state that im-
paired neuromuscular control of the
spine leads to spine instability, because
we do not have easy access to the central
nervous system and the muscles it acti-
vates. For example, we do not completely
understand how the various subsystems
at supraspinal and spinal levels process
afferent signals from sensory receptors to
journal of orthopaedic & sports physical therapy | volume 49 | number 6 | june 2019 | 419
create efferent signals and how accurately
trunk muscles execute these commands
to stabilize the spine. Fortunately, there
are powerful systems-based approaches
that can be used to estimate inaccessible
signals and systems.80 These tools have
been successfully applied to the analysis
of complex man-made machines and are
starting to be employed to study spine
control and back pain.27,30,33,57,89,107 Robot-
ic/actuated systems are often used in con-
junction with systems-based approaches
to improve precision in applying input
(eg, perturbations to the spine) and mea-
suring output (eg, kinematic response to
perturbations).30,33,51,91,106-108 This preci-
sion improves the systems-based model-
ing used to estimate inaccessible signals
and systems.
Modeling of spine control using
systems-based approaches can provide
insight into control pathways used to
maintain spine stability. The central ner-
vous system represents a highly adaptive
control system, which has been shown
to alter spine control depending on task
instructions, visual cues, and frequency
content of disturbances to the trunk,106
or in response to changing task dynam-
ics.5,75 The central nervous system also
appears capable of identifying corrupted
sensory signals in order to downplay
their influence in spine control13 in favor
of “cleaner” sensory signals30 (ie, sensory
reweighting). Systems-based approaches
may be useful in untangling aspects of
spine control so that impairments in vari-
ous control pathways can be identified.
Modeling of spine control is still in
its early stages. Current models focus
on gross trunk control30,33,75,89,107 and
not segmental control. Difficulties re-
lated to tracking spine kinematics pro-
hibit more detailed modeling. However,
high-precision dual fluoroscopy could be
used in conjunction with systems-based
approaches to develop a new class of
multisegment spine models to identify
segmental instability. Future work should
also expand models of spine control to in-
clude a wider array of spine stabilization
conditions. For instance, some tasks may
promote trunk-on-pelvis stabilization,
such as absorbing a body check in hock-
ey, whereas other tasks may also have the
additional requirement of trunk-in-space
stabilization, such as maintaining an up-
right posture during mogul skiing.106
A major limitation of the earlier static
mechanical definition of spine stability
was the overemphasis of trunk-on-pelvis
stabilization, which ignored the more
subtle need to allow for spine movement
in certain tasks. One could imagine that
a person with a compromised back who
adopts a protective coactivation strategy
would be successful in trunk-on-pelvis
stabilization but lack nuanced control
to stabilize the trunk in space. In line
with this proposal, there is evidence for
reduced motion of the spine (consistent
with a strategy of trunk-on-pelvis spine
protection) to impact quality of balance
recovery (trunk/body in space) after per-
turbation.67,68 From a clinical perspective,
there may be specific stabilization modes,
spine positions or movements, or types of
perturbations that challenge spine stabil-
ity, and without a comprehensive assess-
ment, impairments that threaten stability
may go unnoticed. As discussed earlier,
such impairment may be unique to each
individual, highlighting the need for indi-
vidualized assessment and personalized
treatment approaches.
Current models of spine control pri-
marily focus on feedback pathways used
to stabilize the spine. Although stability
is primarily achieved through feedback
control,90 the importance of feedforward
control requires consideration. The cen-
tral nervous system, in the presence of
predictable internal perturbation (eg, in
response to a planned movement of the
upper extremities38,45) and/or predict-
able external perturbation (eg, contact
with the ground when walking4), can
protect the spine by adjusting trunk
muscles to counteract disturbances in
a feedforward manner. Feedforward
control can be highly selective in tuning
muscle activation to the dynamics of a
task,14 producing skillful and efficient
control of human movement.24,25 In the
 [ clinical commentary
presence of pain, however, the ability the past arose from a too-narrow per-
to use feedforward commands to use spective, which may have led to unneces-
more adept trunk control appears to be sary debate.72 In an attempt to push our
impaired.40,44 This raises an interesting boundaries of understanding, we apply
question: does the presence of pain or, stability concepts to 2 nontraditional
possibly, the fear of pain override the contexts to demonstrate how the frame-
ability to use more skillful and efficient work could integrate diverse scientific
control in favor of a more basic mode knowledge.
of control (ie, coactivation strategy) In this paper, we have expanded our
intended to protect against potential understanding of spine stability from a
segmental instability? Future models static mechanical concept to a dynamic
of spine control could incorporate feed- control concept. This control concept
forward pathways to study the degree can be extended further to investigate
to which people with back pain rely on not only the control of a mechanical sys-
feedback versus feedforward control. tem (the spine), but also the control of a
neural signal, such as nociceptive affer-
Potential Expansion of Stability ence. Nociceptors have an undesirable
Concepts and Feedback Control attribute that is present in all unstable
This section introduces concepts that systems—a positive feedback loop. A
are speculative, given the lack of inves- positive feedback loop is created when
tigation in the literature. Despite this nociceptors release chemical mediators
lack of specific evidence, the underly- that sensitize and activate nearby noci-
ing concepts of stability and feedback ceptors and increase excitability in spi-
control are based on mathematical laws nal neurons50 (FIGURE 4). Consequently,
that are applicable to any system. Also, the same magnitude of noxious stimu-
this commentary expresses the view that lus progressively increases the magni-
problems with interpreting stability in tude of nociceptor afferent discharge,
Input Output
+
CNS Tissue damage Noxious afferents
Nociceptors
Noxious afferent
Perception of pain
+ Chemical release
(bradykinin, ACh,
histamine, substance P)
Output
Perception
of pain CNS interpretation
+
(eg, unpleasant Spinal neurons
experience)
Chemical release + their spine is vulnerable to instability
(glutamate)
Analgesic therapies
(eg, TENS, opioid – their spine through excessive coactiva-
peptides)
Perception of pain
FIGURE 4. Expansion of the concept of stability to integrate neural processes involved in the experience of
pain. In this new subsystem, which represents a simple model of nociceptive/pain pathways, there are positive
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
systematically identify these influences so that targeted treatment can be applied to minimize positive feedback
pathways and/or accentuate negative feedback influences. The objective of the overall system is to have a surplus
of negative feedback to control pain. Abbreviations: ACh, acetylcholine; CNS, central nervous system; TENS,
transcutaneous electrical nerve stimulation.
420 | june 2019 | volume 49 | number 6 | journal of orthopaedic & sports physical therapy
]
thus amplifying ascending inputs and
ultimately the pain response over time,
often referred to as sensitization or a
“wind-up” phenomenon.50 To maintain
stable, healthy homeostasis, dynamic
control concepts could be used to define
and control the pain processes respon-
sible for pain magnification and persis-
tence. This would involve the expansion
of the system to include both peripheral
and central processes that regulate pain,
thus reflecting a more comprehensive
perspective on back pain.
As a second issue for consideration,
unintentionally, through the overem-
phasis of the term spine instability,
spine researchers and health care pro-
viders may have created another positive
feedback loop that is acting in the gen-
eral population to amplify the severity
of back pain. Messages that imply that
the spine is highly susceptible to injury
from instability give the impression that
the spine is a poorly designed system
that may easily fail. With this mental
image of fragility, individuals may con-
sciously or unconsciously protect the
spine by increasing muscle coactivation.
As mentioned earlier, some additional
coactivation may represent a functional
adaptation to address mechanical and
neural deficits that threaten spine sta-
bility. But some individuals may elevate
trunk coactivation beyond that neces-
sary to complete a task, leading to a
Input
Noxious nonfunctional adaptation that drives
afferents
the pain disorder (see O’Sullivan76 for
a case study). A positive feedback loop
may be created when individuals believe
and react to this threat by protecting
tion, such that it exceeds the demands
for stabilization, which causes pain that
then reinforces the notion that the spine
is vulnerable (see FIGURE 5). At present,
there is some limited research to support
this hypothesis. For example, back pain
interventions that include education
that the spine is a highly robust struc-
ture have some evidence of efficacy.84
Given the potential for an iatrogenic
mechanism for the persistence of pain, ate an environment that might result in
at least in some individuals, this is worth segmental instability if the contribut-
exploring. ing features converge on that outcome
(eg, laxity and failure of neural control
CONCLUSION to compensate). Even if these factors do
not cause instability, they increase the
T
o conclude, we return to the demands for maintaining stability, which
title of this paper, “Are Stability and could underpin development of pain and
Instability Relevant Concepts for injury secondary to fatigue or increased
Back Pain?” As expressed here, our un- tissue loading.
derstanding of spine stability has evolved New scientific and technical advances
over time and continues to evolve. Knowl- that help access variables of interest and
edge gained related to spine function and define elements of spine control, com-
back pain is linked with advances in our bined with more comprehensive assess-
understanding of stability and instability, ment of spine control, will hopefully shed
making the terms very relevant. some additional light on the relevance of
We know that stability is also relevant instability. Future directions for research
to the central nervous system. Several could continue the expansion of the con-
studies have shown that the central ner- cept of stability. This expansion might in-
vous system carefully monitors stability clude adapting ideas used for controlling
demands on the spine. We do not know mechanical variables (ie, spine kinemat-
whether the spine experiences unstable ics) to control neural signals representing
behavior resulting in injury. Neural and nociceptive afferents and the perception
mechanical coupling reduces the risk of of pain, thus reflecting a broader perspec-
instability in a healthy spine. However, tive on back pain.
in an injured spine, joint laxity, neural As Bellman7 indicated in our opening
inhibition, and reduced force-generating epigraph, instability is a weighty term
capacity and endurance of muscles cre- not without history. Although speculative
It appears
you have an
Output
+ Input
unstable spine.
Perception of pain Perception that the spine is fragile
CNS
interpretation Noxious
+ subsystem + afferent
CNS Spinal neurons
motor subsystem
subsystem
+ + Noxious
afferent
+
Trunk muscle
Spine
coactivation Nociceptor
neuromuscular subsystem
subsystem Tissue
damage
Possible pathway for iatrogenic pain
FIGURE 5. In this context, we expand the system to include a social factor that could influence back pain. In this
system, information from clinicians indicating that the spine is fragile represents input into the general population,
which may result in some individuals changing their spine control strategy to a coactivation strategy that could
lead to excessive tissue loading and damage. This could subsequently act as input into nociceptive/pain pathways
(nociceptors, spinal neurons, and CNS interpretation subsystems). The output, the perception of pain, is then fed
back to strengthen the perception that the spine is fragile. This, in turn, drives a positive feedback loop that creates
back pain that is maintained by iatrogenic means. If iatrogenic maintenance of back pain exists, then one solution
would be to change messaging to the general population, indicating that the spine is a highly robust structure.
Abbreviation: CNS, central nervous system.
journal of orthopaedic & sports physical therapy | volume 49 | number 6 | june 2019 | 421
at this point, it is possible that the use of
terms like spine instability is contribut-
ing to the persistence of back pain that
is iatrogenic in nature. If iatrogenic back
pain indeed exists, then messages sur-
rounding the spine and its susceptibility
must be thoughtfully posed to the general
public to avoid maladaptive strategies in
those individuals who would otherwise
be healthy and productive.
Finally, the systems-based framework
used in this commentary has the poten-
tial for interdisciplinary integration of
knowledge, which is currently lacking
in the spine community. We use stabil-
ity concepts to showcase the benefits of
systems-based approaches in unifying the
science surrounding the etiology of back
pain. Our understanding of back pain is
far from complete, but the framework
provides a means to move forward in a
rigorous and coherent way. t
ACKNOWLEDGMENTS: The forum on which this
body of research was based, “State-of-the-
Art in Motor Control and Low Back Pain:
International Clinical and Research Expert
Forum,” was supported by the National
Health and Medical Research Council of
Australia, in collaboration with the North
American Spine Society. The forum was
chaired by Dr Paul Hodges.
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