ORIGINAL ARTICLE

New insight into motor adaptation to pain revealed by a

combination of modelling and empirical approaches
P.W. Hodges
1
, M.W. Coppieters
1
, D. MacDonald
1
, J. Cholewicki
1,2
1 The University of Queensland, Centre of Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences,
Brisbane, Qld, Australia
2 Center for Orthopedic Research, Michigan State University, Lansing, MI, USA
Correspondence
Paul W Hodges
E-mail: p.hodges@uq.edu.au
Funding source
National Health and Medical Research Council
(Australia).
Conicts of interest
None declared.
Accepted for publication
21 December 2012
doi:10.1002/j.1532-2149.2013.00286.x
Abstract
Background: Movement changes in pain. Unlike the somewhat
stereotypical response of limb muscles to pain, trunk muscle responses are
highly variable when challenged by pain in that region. This has led many
to question the existence of a common underlying theory to explain the
adaptation. Here, we tested the hypotheses that (1) adaptation in muscle
activation in acute pain leads to enhanced spine stability, despite variation
in the pattern of muscle activation changes; and (2) individuals would use
a similar signature pattern for tasks with different mechanical demands.
Methods: In 17 healthy individuals, electromyography recordings were
made from a broad array of anterior and posterior trunk muscles while
participants moved slowly between trunk exion and extension with and
without experimentally induced back pain. Hypotheses were tested by
estimating spine stability (Stability Index) with an electromyography-
driven spine model and analysis of individual and overall (net) adapta-
tions in muscle activation.
Results: The Stability Index (P < 0.017) and net muscle activity
(P < 0.021) increased during pain, although no two individuals used the
same pattern of adaptation in muscle activity. For most, the adaptation was
similar between movement directions despite opposite movement
demands.
Conclusions: These data provide the rst empirical conrmation that, in
most individuals, acute back pain leads to increased spinal stability and
that the pattern of muscle activity is not stereotypical, but instead involves
an individual-specic response to pain. This adaptation is likely to provide
short-term benet to enhance spinal protection, but could have long-term
consequences for spinal health.
1. Introduction
Trunk muscle control changes in back pain. This
includes opposite changes of decreased (Hodges and
Richardson, 1996; Leinonen et al., 2001; MacDonald
et al., 2009) and augmented (Radebold et al., 2000;
Hodges et al., 2003b) muscle activity in acute (Hodges
et al., 2003b) and chronic pain (Radebold et al., 2000)
and during symptom remission (Hodges and Richard-
son, 1996; MacDonald et al., 2009) without consis-
tency in motor adaptation between muscles, patient
groups or experimental methods (van Dieen et al.,
2003). This underpins confusion and debate, particu-
larly when motor changes are used to design exercise
interventions for back pain (OSullivan, 2000; McGill,
2002; Richardson et al., 2004). Current treatments
target opposite goals to enhance (McGill, 2002) or
decrease (Richardson et al., 2004) activity of specic
muscles. Although variable responses in back pain
imply absence of a consistent outcome of the adapta-
1 Eur J Pain (2013) 2013 European Federation of International Association for the Study of Pain Chapters
tion (van Dieen et al., 2003), the alternative interpre-
tation is that variability reects the trunk muscle
systems redundancy (i.e. multiple muscle activation
strategies to achieve similar goals) (Latash and Anson,
2006). Unfortunately, with few exceptions (Radebold
et al., 2000), most studies investigate few muscles,
which limits consideration of overall responses to
pain.
Widely accepted theories of motor adaptation to
pain predict stereotypical responses. The pain adapta-
tion theory predicts decreased activity of muscles pro-
ducing painful movements and facilitation of
antagonists (Lund et al., 1991). The vicious cycle
theory predicts increased activity, with further pain
induced by accumulation of metabolites from muscle
ischaemia (Roland, 1986). These stereotypical adapta-
tions are inconsistent with variable trunk muscle
changes in back pain (van Dieen et al., 2003). Recent
theoretical work proposes the adaptation of motor
control in acute pain involves redistribution of activity
within and between muscles with the goal of protect-
ing the body segment from real or perceived threat of
pain/injury in a manner specic to the individual/
context (Hodges and Tucker, 2011). Yet despite varia-
tion in trunk muscle responses, the overall outcome
will be enhanced spine stability (Hodges and Tucker,
2011), dened as the potential to resist perturbations
causing intervertebral displacements (Reeves et al.,
2007). This adaptation could be task-specic or indi-
viduals may use a similar signature adaptation across
a range of tasks. Evidence of increased spine stability
using mathematical simulation of a small number of
patterns of increased muscle activity thought to be
common in back pain provides some evidence for this
hypothesis (van Dien et al., 2003). However, empiri-
cal evidence from muscle recordings is required to
take into account the complexity of potential changes
in muscle activity, which may include increased and
decreased muscle activity.
We tested the hypothesis that motor adaptation in
acute pain enhances spine stability despite variation in
the adaptations pattern (i.e. which muscles are
affected, and whether activity increases or decreases).
We also tested the hypothesis that individuals would
use a similar signature pattern in different tasks.
Hypotheses were tested by estimating spine stability
using an electromyography (EMG)-driven biome-
chanical model and analysis of empirical data from
EMG recordings from a broad array of trunk muscles
in response to experimentally induced back pain.
2. Methods
2.1 Participants
Seventeen males [mean (standard deviation) age 25(6)
years, height 177(8) cm, weight 75(12) kg] participated
in the study. Participants were excluded if they had any
history of low back pain that had limited function or caused
them to seek medical or allied health treatment. The Insti-
tutional Medical Research Ethics Committee approved the
study and all procedures were conducted in accordance with
the Declaration of Helsinki. Participants provided written
informed consent.
2.2 Electromyography
EMG activity was recorded bilaterally from three trunk
exor muscles [rectus abdominis (RA), obliquus internus
(OI) and externus abdominis (OE)] and three trunk extensor
muscles [thoracic (TES) and lumbar erector spinae (LES) and
latissimus dorsi (LD)] using pairs of self-adhesive electrodes
(3M, St. Paul, MN, USA) at sites described in detail elsewhere
(Cholewicki et al., 1997) and shown in Fig. 1A and B. These
are the only trunk muscles accessible for surface EMG
recording and provide good representation of overall trunk
muscle activity and the resultant spinal loads (Cholewicki
et al., 1997). Skin was prepared with mild abrasion and
wiped with alcohol. EMG data were pre-amplied 1000
times close to the body (Neurolog, Digitimer, Welwyn
Garden City, Hertfordshire, UK), amplied further for two
times, ltered between 20 and 1000 Hz (Neurolog) and
sampled at 2000 Hz using a Power1401 (Cambridge Elec-
tronic Designs, Cambridge, UK).
2.3 Procedure
Participants sat in frame on a slanted seat that was designed
to position the lumbar spine in a mid-range lordosis
(Fig. 1C). The pelvis was xed with padded supports placed
in front and behind the participant. A harness was placed
Whats already known about this topic?
Movement adapts in pain, but variability in the
response to pain has led some to suggest that
there is no common mechanism or outcome of
the adaptation.
What does this study add?
This study shows that spine stability is systemati-
cally increased when low back pain is induced
experimentally.
But, this is achieved by patterns of muscle acti-
vation that vary between individuals.
The adaptation may have short-term benet, but
with potential long-term consequences.
New insight into motor adaptation to pain P.W. Hodges et al.
2 Eur J Pain (2013) 2013 European Federation of International Association for the Study of Pain Chapters
over the shoulders with a tilt sensor attached at the approxi-
mate level of T9 to measure the angular displacement of the
trunk. This data was used to align EMG activity with respect
to trunk angle rather than a specic time. The task involved
slow trunk movement between approximately -20 degrees
(extension) and +20 degrees (exion) for two repetitions in
each direction. The range of motion was monitored on line
and feedback provided to the participant if required. The
rationale for this task is that although the activity of the
trunk exor and extensor muscles is required to maintain
the extended and exed posture against gravity, respectively,
no resultant moment acts on the trunk in the mid-upright
position and any recorded trunk muscle activity is that
required to maintain stability (control upright trunk position
if perturbed). This position is characterized by the lowest net
muscle activity (Cholewicki et al., 1997). The quasi-static
analysis was enabled by movement at a slow speed that was
controlled with feedback from a metronome. An auditory
signal was provided each 1 s and participants were encour-
aged to take 7 s to complete the movement in each direction.
Trials were performed before and during pain induced by
injection of hypertonic saline (5% concentration; 1.5 mL
bolus injected over ~20 s) into the right longissimus muscle
~5 cm lateral to the spinous process of L4 (Fig. 1D). Pain was
reported on an 11-point numerical rating scale (NRS)
anchored with no pain and worst pain imaginable. In 15
participants, data were also recorded for two trials after the
pain had resolved when participants reported 0 on the NRS.
Maximal voluntary contractions (MVC) against manual
resistance were performed for each trunk muscle for normal-
ization of the EMG recordings for calculation of the spine
Stability Index (SI; see below). The tasks were: TES and LES
trunk extension in prone with resistance to the thighs and
upper trunk; LD shoulder adduction and extension against
manual resistance at the elbow with the participant in sitting
and the arms abducted and externally rotated 90 degrees; RA
trunk exion in supine with resistance to the thighs and
upper trunk; OE and OI trunk rotation in supine with the
knees bent and resistance applied to the bent knees and the
arms (in 90 degrees shoulder exion and full elbow exten-
sion). Contractions were maintained for ~3 s and the largest
amplitude over three repetitions recorded for analysis.
2.4 Data analysis
Data analysis was conducted using Matlab (The MathWorks,
Inc., Natick, MA, USA). The QRS complexes of the electro-
cardiogram (heart beat) were removed from the raw EMG
using a modied turning point lter and adaptive sampling
(Aminian et al., 1988). Next, EMG data were rectied and
low pass ltered at 1 Hz (dual pass, fourth-order Butter-
worth). The net muscle activity was quantied by calculating
the root mean square (RMS) of the 12 EMG signals at each
trunk angle. The minimum net muscle activity (minimum
RMS EMG) was identied and the trunk angle at which this
occurred was recorded (referred to as the neutral position).
Data for this analysis were not normalized to MVC, as they
were used to estimate the net overall muscle activity and to
identify the trunk position associated with minimum net
muscle activity. However, this analysis did not take into
account the relative contribution of each muscle to spine
stability because it ignored differences in moment arm and
muscle cross-sectional area. These factors were taken into
account in calculation of the spine SI.
For calculation of the spine SI, EMG data in the neutral
position were used in a spinal stability model that has been
described in detail elsewhere (Cholewicki and McGill, 1996).
Briey, MVC-normalized EMG amplitudes recorded from 12
muscles were used to estimate muscle force and stiffness for
90 muscle fascicles represented in the model. The SI quan-
ties the average curvature of the systems potential energy
in the vicinity of static equilibrium. This potential energy is
the difference between work performed by external forces
acting on the spine and elastic energy stored in muscles,
whose stiffness is proportional to the muscle force. The index
is a function of the rotational stiffness at each of the 18
degrees of freedom in the model (six lumbar intervertebral
joints and three rotations at each) and provides a compara-
tive measure of structural robustness of the spine to external
disturbances that would cause intervertebral displacements
(Howarth et al., 2004). The quasi-static character of the tasks
(resultant trunk velocity was approximately 6/s) justied
the use of a static, structural buckling analysis in this study
Figure 1 Experimental set up. Surface electromyography electrode
placement for recording of (A) trunk exor muscles [rectus abdominis
(RA), obliquus externus (OE) and internus (OI) abdominis] and (B) exten-
sor muscles [latissimus dorsi (LD), thoracic (TES) and lumbar (LES)
erector spine]. (C) Participant positioned in the frame with pelvic
restraint and tilt sensor to record trunk angle relative to gravity. (D)
Placement of the needle for injection of hypertonic saline in the experi-
mental pain trials.
P.W. Hodges et al. New insight into motor adaptation to pain
3 Eur J Pain (2013) 2013 European Federation of International Association for the Study of Pain Chapters
and this approach was validated previously (Cholewicki
et al., 1997). Data were averaged over two repetitions.
2.5 Statistical analysis
The spine SI and minimum net muscle activity were com-
pared between Pain conditions (no pain vs. pain) and
between Directions of movement (front-back vs. back-front)
with repeated measures analyses of variance (ANOVA). Post
hoc testing was undertaken with Duncans multiple range
test. Differences in EMG for individual muscles (for data
from all participants considered together) were investigated
by comparison between trials with and without Pain,
between Directions and between Muscles with an ANOVA. In
addition, data were displayed pictorially to evaluate the
changes in activity of each muscle for each individual par-
ticipant. Thus, changes in activity for each muscle were pre-
sented in black if activity increased, grey if the activity
decreased, and white if the activity did not change. For this
analysis, data were dened as increased or decreased if they
changed by > 15% (Chapman et al., 2008) from values
recorded in the trials without pain. The proportion of indi-
vidual participants who had an increase or decrease in activ-
ity for each individual muscle was recorded, as were the
number of participants who had the same or opposite change
in muscle activity between directions of movement. Data
were presented descriptively for these analyses. Data are
presented as mean (standard deviation) throughout the text.
Signicance was set at P < 0.05.
3. Results
3.1 Pain
Participants reported peak pain of 6.1(2.7) out of 10
on the NRS after injection of hypertonic saline into
longissimus. All movement trials were completed
before pain fell below 4 out of 10 on the NRS.
3.2 Minimum net muscle activity
The mean (range) amplitude of EMG across muscles at
baseline was 1.9 (0.27.8) % MVC. Fig. 2 shows data
for a representative participant. The heavy dashed line
that indicates the net muscle activity (RMS of all 12
trunk muscles EMG) clearly demonstrates an increase
in the minimum net muscle activity during pain. With
slow movement from front-back, the minimum net
muscle activity increased by 30(42)% during pain, and
by 14(34)% when moving from back-front (Interac-
tion: Pain*Direction P = 0.021, Post hoc: front-back
P < 0.001 and back-front P = 0.027, Fig. 3A). The
minimum net muscle activity increased during pain in
76% (13 out of 17) and 65% (11 out of 17) of partici-
pants for the front-back and back-front movements,
respectively. In three participants, the minimum net
muscle activity decreased in both movement direc-
tions. Analysis of individual muscles showed that even
in those participants with decreased minimum net
muscle activity, the activity of some muscles was
increased (see below).
An additional analysis was conducted for the 15
participants who had data available after the resolu-
tion of pain. In those participants, the minimum net
muscle activity after pain was not different to that
before pain (Post hoc: front-back P = 0.710, back-
front P = 0.740, Fig. 3).
3.3 Spine SI
The spine SI was calculated at the trunk angle at
which the minimum net muscle activity was identied
(neutral position). Concomitant with the minimum
net muscle activity, the spine SI was increased during
pain and this was similar for both directions of trunk
motion (Main effect: Pain P = 0.017, Interaction:
Pain*Direction P = 0.15; Fig. 3B). The SI was
increased in the back-front direction in 82.4% (14 out
of 17) of participants, and 70.6% (12 out of 17) of
participants in the front-back direction. There was no
difference in the spine SI between the two directions
of motion (Main effect: Direction P = 0.240). For the
15 participants who had data available after the reso-
lution of pain, the SI after pain was not different to
that before pain (Post hoc: P = 0.83, Fig. 3).
Figure 2 Representative electromyography (EMG) activity as a function
of trunk angle during slow movement from front to back. Trunk extensor
(grey line) and exor (black line) muscle EMG is shown. The root mean
square (RMS) EMG activity of all 12 trunk muscles (net muscle activity) is
shown as a thick dashed line and its minimum is indicated at angle zero
with the vertical dashed line. Note the increase in the minimum net
muscle activity during pain.
New insight into motor adaptation to pain P.W. Hodges et al.
4 Eur J Pain (2013) 2013 European Federation of International Association for the Study of Pain Chapters
3.4 EMG amplitude for individual muscles at
the angle of minimum net muscle activity
When data were analysed for the entire participant
group together, TES EMG activity on the right side of
the body was increased in the neutral position (Inter-
action: Pain*Muscle P = 0.009, Post hoc: P < 0.001;
Fig. 4) and, although not signicant, there was a ten-
dency for increased TES activity on the left side (Post
hoc P = 0.064). Left OE EMG was decreased (Post hoc:
P = 0.042). These changes were not dependent on the
direction of trunk movement (Interaction: Direction*
Pain P = 0.100, Interaction: Direction*Pain*Muscle
P = 0.280). There was no difference for any other
muscle (Post hoc: P-value range P = 0.120 to P = 0.900).
Analysis of the EMG data for individual muscles
from participants as a group provides limited under-
standing of the changes in muscle activity with pain in
individual participants. Fig. 5 provides a visual
summary of the complex and variable pattern of
change in trunk muscle activity during pain. Panel A is
organized with pairs representing the data for indi-
vidual participants during the two movement direc-
tions (top front-back, bottom back-front). Panel B
shows the proportion of participants in which the
same response was identied in the front-back and
back-front directions, i.e. the consistency of the
change in muscle activation between task directions.
The change in EMG amplitude for individual muscles
was opposite between trunk movement directions in
only 10.7% of muscles across all participants. Thus,
the adaptation was almost identical for the two con-
ditions, despite the opposite direction of motion.
There was considerable variation in the pattern of
change in trunk muscle activity between participants
and no two participants showed an identical pattern of
change. Across participants and directions, the
number of muscles in which EMG increased by 15%
or more ranged between 2 and 10 (Fig. 5A). In the
front-back direction, left OI EMG was increased in
65% of participants; left RA, LD and TES in 59%; right
RA, OE, OI, LES and TES in 53%, and right LD, left OE
and left LES in 3647% (Fig. 5C). With the back-front
direction, EMG increased by 15% or more in 59% of
participants for right OE, left OI and right TES and
LES; 53% for left LD and right OI; 47% for left and
right RA; 1735% for left TES and LES, left OE and
right LD (Fig. 5D). Activity was most commonly
decreased by 15% or more for muscles that rotate the
trunk to the right (OE on the left side of the body:
front-back 53%; back-front 58%; right OI: both
directions 35%) and the left LES (2935%). All
other muscles were decreased by more than 15% in
less than 29% of participants.
Figure 3 Mean (standard deviation) of (A) minimum net muscle activity
(minimum root mean square electromyography [EMG] of all 12 trunk
muscles) and (B) Stability index (SI) before and during experimental pain.
Minimum net EMG activity and SI are also shown for the 15 participants
with measures made after the resolution of pain. Note the increase in both
parameters during pain. *P < 0.05.
Figure 4 Mean electromyography (EMG) activity for each muscle at the
trunk angle identied to have the minimum net muscle activity (minimum
root mean square EMG of all 12 trunk muscles) for front to back (left) and
back to front trunk movements. Standard deviation is shown. RA, rectus
abdominis; OE, obliquus externus abdominis; OI, obliquus internus abdo-
minis; LD, latissimus dorsi; TES, thoracic erector spine; LES, lumbar
erector spine; r, right; l, left. *P < 0.05.
P.W. Hodges et al. New insight into motor adaptation to pain
5 Eur J Pain (2013) 2013 European Federation of International Association for the Study of Pain Chapters
4. Discussion
Although experimental back pain induced variable
patterns of increased and decreased trunk muscle
activity, when all muscles were considered together,
the net trunk muscle activity and estimated spine sta-
bility increased. This nding concurs with the hypoth-
esis that the nervous system responds to pain by
increasing muscle activity to protect the spine, validat-
ing a key prediction of a contemporary theory of
motor adaptation to pain (Hodges and Tucker, 2011).
4.1 Methodological considerations
The present results require consideration of several
limitations. First, analysis based on net trunk muscle
EMG activity is limited because it does not recognize
the muscles different cross-sectional areas, moment
arms and effects on spine stability. Therefore, we also
computed the SI, which accounts for these variables.
Congruence between ndings from both methods aids
interpretation of EMG data from individual muscles.
Further, restriction of hip motion limits potential for
hip muscle adaptation. Although, this improves accu-
racy of our estimates of spine stability, investigation
including the hip would provide additional insight of
adaptation strategies available in a real-world context.
Second, the biomechanical model used to estimate
the SI is static and can only provide analysis of the
spine at a single point in time. However, the spine is a
dynamic system with feedback control. Therefore, the
slow movement task was quasi-static to limit dynamic
aspects of trunk muscle responses.
Third, adaptation to pain was present during a task
requiring low muscle forces. Although relevant to
everyday activity such as standing or sitting without a
back support, further work should determine whether
adaptation is similar in higher effort tasks.
4.2 Spine stability increased despite variable
responses of trunk muscles to pain
Theoretical predictions of motor adaptation to pain are
variable. Decreased activity of muscles producing a
painful movement (agonist) and increased antagonist
activity predicted by the pain adaptation theory to
reduce movement amplitude/velocity was not sup-
ported by our data; there was neither consistently
decreased trunk exor and increased extensor activity
during back-front movement, nor the converse with
opposite movement. Although this prediction is sup-
ported in simple systems with few muscles [e.g. elbow
(Ervilha et al., 2004), jaw (Svensson et al., 1995; Sohn
et al., 2000) or ankle (Graven-Nielsen et al., 1997)],
the complexity of the redundant trunk muscle system
appears not associated with stereotypical change.
Decreased activity in some muscles is not explained
by vicious cycle theory predictions of increased activ-
ity. Other theories propose some back pain is associ-
ated with spine instability (Panjabi, 1992). Although
Figure 5 Individual data for change in elec-
tromyography (EMG) activity of each muscle
during pain. (A) Data are shown for each par-
ticipant (S117) in the front to back (F-B;
upper) and back to front (B-F; lower) directions
of trunk movement. Black indicates increased
(15% or more) EMG activity, grey indicates
decreased (15% or more) activity and white
indicates a change of less than 15% from the
pre-pain condition. (B) The proportion of par-
ticipants who had the same change in EMG
activity for both tasks. (C) The proportion of
participants with increased, no change and
decreased EMG for each muscle during front to
back movement. (D) The proportion of partici-
pants with increased, no change and
decreased EMG for each muscle during back to
front movement. RA, rectus abdominis; OE,
obliquus externus abdominis; OI, obliquus
internus abdominis; LD, latissimus dorsi; TES,
thoracic erector spine; LES, lumbar erector
spine; r, right; l, left.
New insight into motor adaptation to pain P.W. Hodges et al.
6 Eur J Pain (2013) 2013 European Federation of International Association for the Study of Pain Chapters
possible when passive spine support is disrupted (e.g.
trauma), this was not present in this experiment
where pain induced increased spinal stability without
change in passive stiffness.
The observed individual-specic, non-stereotypical
changes in muscle activity parallel the predictions of a
contemporary theory of adaptation to pain, which
states redistribution of activity between muscles
increases net muscle activity to protect the painful part
(Hodges and Tucker, 2011). Several earlier experimen-
tal observations provided foundation for this predic-
tion. First, a variable pattern of increased/decreased
muscle activity was reported for a limited number of
trunk muscles with experimental back pain (Hodges
et al., 2003b), but the net effect on spine stability was
not assessed. Others proposed a net increase in trunk
muscle activity based on literature review (van Dieen
et al., 2003) and biomechanical model simulation of
three stereotypical patterns of increased muscle activity
increased stability (van Dien et al., 2003). Although
promising, that study did not account for diversity of
adaptation identied here and did not include
co-existent decreased activity of some muscles which
could counteract the effect of increased activation.
Finally, recent work showed increased trunk stiffness in
response to perturbation during remission from recur-
ring back pain (Hodges et al., 2009). Although provid-
ing some validation of the interpretation of the present
data, that method could not distinguish between active
and passive contributions to spine stiffness.
Although some argue adaptation to augment spine
stiffness would be necessary to compensate for
reduced support from passive structures (i.e. injury)
(Panjabi, 1992; van Dien et al., 2003), this cannot
explain our data as pain was induced without injury.
However, adaptation of large supercial muscles may
compensate for a decreased contribution of the deeper
muscles to spine stiffness. Deeper trunk muscles, such
as transversus abdominis, contribute to spine stability
(Hodges et al., 2003a, 2004; Barker et al., 2005) but
are consistently compromised when clinical (Hodges
and Richardson, 1996) or experimental back pain
(Hodges et al., 2003b) is present. Activity of deep
muscles was not monitored here.
Experience of pain, independent of tissue injury,
was sufcient to trigger a response that enhanced
spine stability. This parallels earlier observations of
increased/decreased muscle activity in experimental
muscle pain (Hodges et al., 2003b). A similar response
can be evoked by threat of pain, in the absence of
nociceptor stimulation (Moseley et al., 2004). The
nervous system appears to take protective action in
the presence of both a real or predicted threat to body
tissues. This has implications for patients with persis-
tent back pain as adapted responses may be main-
tained, despite tissue healing. Although this study
cannot resolve whether the adaptation was caused by
nociceptive stimulation or the threat of pain, this does
not detract from the key observations.
Is the adaptation to increase spine stability/
protection helpful? One interpretation is the adapta-
tion prevents further pain and/or injury. However, this
benet may be limited to the short term, with poten-
tial for negative long-term consequences caused by:
sustained increase in spine load from the net increase
in muscle activity (Kumar, 1990; Marras et al., 2004),
impaired spine movement and its contribution to
shock absorption/dampening (Mok et al., 2007) or
reduced movement variability which compromises
load sharing between spinal structures (e.g. muscles,
joint surfaces, ligaments) which is linked to pain in
other regions (Hamill et al., 1999). Here, the adapted
motor response resolved once pain recovered, but
many individuals with recurring pain maintain abnor-
mal muscle activation during symptom remission
(Hodges and Richardson, 1996; MacDonald et al.,
2009). Whether, maintenance of the adaptation
underlies persistence/recurrence of pain requires
investigation in longitudinal studies.
The SI did not increase in three participants in the
front-back direction and ve participants in the oppo-
site direction. Instead, the SI decreased by 12(8) and
8(5)%, respectively. Why this subgroup had the oppo-
site response is unclear, but most of these participants
(two out of three and three out of ve, respectively)
had an SI in the highest ve of all participants prior to
pain induction. Their SI may have already exceeded
that required to complete the task and a modied
pattern of muscle activity to achieve stability during
pain may have been more important than an absolute
increase in SI. It is also possible that spine stability
increased during pain, but using muscles other than
those recorded (e.g. quadratus lumborum, psoas
major).
4.3 The pattern of change in muscle activity
varied between individuals
Inconsistent with earlier theories (Roland, 1986; Lund
et al., 1991), the nervous system did not change
muscle activity stereotypically during pain, but the
outcome of adaptation was predictable. In the redun-
dant trunk muscle system, many solutions are avail-
able to increase stability. There are several reasons
why an individual may select a specic pattern. First,
the strategy may be a learnt behaviour based on
P.W. Hodges et al. New insight into motor adaptation to pain
7 Eur J Pain (2013) 2013 European Federation of International Association for the Study of Pain Chapters
habitual postures or patterns of movement [e.g. sitting
with extension from lumbar to mid-thoracic levels
favours TES activity (Claus et al., 2009; Astfalck et al.,
2010) and people who naturally sit in this manner
may adopt a strategy involving this muscle]. Second,
anthropometry (relative length of segments) may
inuence moment arms and response selection. Third,
adaptation may relate to the site of pain. The left OI
muscle, which rotates the trunk to the left (away from
the posterior right injection site), most commonly
increased activity. The pattern of adaptation to pain
may also relate to movement subgroups identied in
back pain in the clinical literature (Janda, 1996;
Sahrman, 2002; Dankaerts et al., 2006).
Did individuals use a consistent pattern of adapta-
tion between tasks? Largely, the pattern was similar
between tasks; only 10% of the adaptations were
opposite in direction (e.g. decreased with one move-
ment but increased with the other) and the muscles
that had most consistently augmented activity (e.g.
trunk rotator muscles such as the oblique abdominal
muscles) were rarely affected in an opposite manner
between tasks for an individual. Thus, many partici-
pants appeared to adopt a relatively consistent
response during pain. This concurs with the clinical
assumption that back pain patients can be classied
into some movement subgroups regardless of task.
5. Conclusion
This study provides the rst empirical conrmation
that, in most individuals, acute back pain is associated
with adaptation of the trunk muscles in a manner
that increases spinal stability and is consistent with
the goal of enhancing protection of the spine, but the
pattern of muscle activity is not stereotypical across
individuals. Instead, the adaptation involves an
individual-specic response that is not predicted by
most existing theories of motor adaptation to pain.
The adaptation of muscle activity is maintained across
tasks within an individual despite opposite movement
demands. This adaptation is likely to provide short-
term benet, but could have long-term consequences
for spinal health.
Author contributions
All authors were involved in conceptualization and design of
the study, acquisition of data, analysis and interpretation of
data. P.W.H. and J.C. drafted the article. All authors discussed
the results and commented on the manuscript and approved
the nal version. P.W.H. acquired funding.
Acknowledgements
This study was supported by a Senior Principal Research
Fellowship to PH [ID1002190] and a project grant
[ID401598] from the National Health and Medical Research
Council of Australia. We thank Wolbert van den Hoorn for
contribution to analysis of EMG data and Kylie Tucker for
assistance with data collection.
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