MODULATION OF THE FLEXION-RELAXATION RESPONSE BY SPINAL MANIPULATIVE THERAPY: A CONTROL GROUP STUDY

Kim Lalanne, DC, MSc, a Danik Lafond, PhD, b and Martin Descarreaux, DC, PhDc

ABSTRACT
Objective: This study evaluated the effects of spinal manipulation on spatiotemporal flexion-relaxation phenomenon parameters in individuals with chronic low back pain. Methods: Twenty-seven adults with chronic low back pain participated in this study and first performed a block of 5 complete trunk flexion-extensions. The experimental group (n = 13) was then submitted to lumbar spine manipulation, whereas the control group (n = 14) was placed in a side-lying control position for 10 seconds. All study participants performed thereafter a second block of 5 trunk flexion-extensions. Trunk and pelvis angles and surface EMG of erector spinae at L2 and L5 were recorded during the flexion-extension tasks. Flexion angles corresponding to the onset and cessation of myoelectric silence, normalized EMG, and the extension-relaxation ratio were compared across experimental conditions. Results: A significant reduction of EMG activity at full trunk flexion at the L2 erector spinae level was observed in the experimental group compared to the control group. No significant effect was seen at L5 in both groups. The experimental group presented a significantly increased postmanipulation FRR at L2, whereas the control group ratio did not vary after the side-lying control position. No significant difference was seen at L5 in both groups. Flexion-relaxation phenomenon onset and cessation angle did not differ across groups or conditions. Conclusions: This study shows that lumbar spine manipulation can, at least for a brief period, modulate stabilizing neuromuscular responses of the lumbar spine in a group of patients with low back pain. (J Manipulative Physiol Ther 2009;32:203-209) Key Indexing Terms: Manipulation; Spinal; Low Back Pain; Electromyography; Chiropractic

ow back pain (LBP) is one of the most frequently seen medical conditions in industrialized countries. Adult LBP lifetime prevalence in industrialized societies has been estimated between 60% and 85%, and instant prevalence is estimated to be between 15% and 30%.1,2 The chronicity of LBP is also common; 6% to 10% of

a Private Practice, Dpartement des sciences de l'activit physique, Universit du Qubec Trois-Rivires, Trois-Rivires, QC, Canada G9A 5H7. b Full Time Professor, Dpartement des sciences de l'activit physique, Universit du Qubec Trois-Rivires, Trois-Rivires, QC, Canada G9A 5H7. c Full Time Professor, Dpartement de chiropratique, Universit du Qubec Trois-Rivires, Trois-Rivires, QC, Canada G9A 5H7. Submit requests for reprints to: Martin Descarreaux, DC, PhD, Full Time Professor, Dpartement de chiropratique, Universit du Qubec Trois-Rivires, 3604 Pavillon de chiropratique, TroisRivires, QC, Canada G9A 5H7 (e-mail: martin.descarreaux@uqtr.ca). Paper submitted July 10, 2008; in revised form November 21, 2008; accepted December 31, 2008. 0161-4754/$36.00 Copyright 2009 by National University of Health Sciences. doi:10.1016/j.jmpt.2009.02.010

patients with acute LBP will develop recurrent or chronic low back pain (CLBP).1 Trunk flexion is controlled by eccentric contraction of the lumbar erector spinae (ES) muscles combined with eccentric contraction of the hip extensors and hamstrings to control pelvic movement.3 Passive stretching of posterior ligaments and capsules also contributes to the control of trunk flexion. Approaching full trunk flexion (75%-80% of full flexion), in healthy individuals, myoelectric activity of the lumbar ES muscles is reduced or silent. First described by Floyd and Silver,4 this response is known as the flexion-relaxation phenomenon (FRP). Different mechanisms have been proposed to explain the FRP, and a shift in load sharing and spinal stabilization from active structures (ES muscles) to passive ligamentous and articular structures (supraspinous, interspinous and other ligaments, intervertebral disks, thoracolumbar fascia) has been postulated by several authors.3,5-7 The lumbar FRP has been found to be present in healthy individuals; its absence is one myoelectric measure that has been used to characterize patients with CLBP.5,8 A lack of neuromuscular coordination between trunk and hip movement could explain the absence of the FRP in patients with CLBP.3,5 Persistent activation of the lumbar ES muscles in 203

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subjects with LBP may consists of a protective splinting response to increase lumbar stabilization, elevated myoelectric activity in response to pain, or an altered motor control strategy.9,10 Optimal lumbar stability is obtained by the relative contributions of passive and active stabilizing elements, which can be modified by pain, angular trunk velocity,7 and loading.3 Other authors11,12 have shown that muscular fatigue could increase the EMG silence period of the ES during a flexion-extension task and that creep and laxity developing in the passive articular tissues result in significant impact on the muscular responses.12,13 Olson et al12 showed that deep cyclic lumbar flexion yielded earlier cessation of EMG during flexion and delayed activation of trunk extensors during extension. The authors associated the prolonged FRP period to reduced lumbar spinal stability and a potential increased risk of lumbar injuries. Chiropractic care is one of many conservative approaches that address LBP. High-velocity, low-amplitude spinal manipulation is the most common treatment used by chiropractors.14 Although capsular stretching by spinal manipulation does not exceed that caused by range of motion of daily living, the resulting stimulus is sufficient to excite capsular mecanoreceptors and induce local neuromuscular responses.15 Few studies have explored the effect of spinal manipulation on surface EMG activity. Krekoukias et al16 recently studied the effect of 2-minute posteroanterior mobilization at L3 on lumbar spinal muscle activity in healthy individuals. Their results showed an average 15.5% decline of EMG activity compared to the control condition. When performed on asymptomatic subjects, spinal manipulation seemed to increase paraspinal EMG activity (raw sEMG) close to the manipulated segment. Such a response is triggered during the first 50 to 200 milliseconds after dynamic thrust.17,18 However, DeVocht et al19 investigated the effect of spinal manipulation in patients with LBP and reported a 25% reduction of paraspinal EMG activity (root mean square [RMS]) at rest on 24 of 31 monitored sites. Previous SMT studies where FRP was used as a dependant variable did not have a control group, and the linkage between the observed changes and the active component of SMT was not clearly established. Therefore, the main objective of this experiment was to evaluate the effects of spinal manipulation on spatiotemporal FRP parameters in individuals with CLBP in a laboratory study and using a control group. Patients with CLBP show heightened EMG activity during FRP maneuver, and such level of cocontraction may reflect an adaptation to prolonged exposure to pain but also an excessive level of spinal stabilization.9 Because spinal manipulations seem to momentarily modify local muscle activation, it was hypothesized that they will temporarily reduce EMG activity (RMS) during a lumbar flexion-extension task and consequently change FRP parameters. The purpose of this study was to evaluate the effects of spinal manipulation on spatiotemporal FRP parameters in CLBP individuals.

METHODS
Participants
Twenty-seven adults with CLBP (14 men and 13 women) participated in this study. To be included in the study, participants had to be male or female aged between 18 and 60 years. They also had to have CLBP (constant or recurrent back pain for more than 6 months). Subjects' characteristics are presented in Table 1. The study participants were randomly assigned to either the experimental (n = 13) or control group (n = 14). The exclusion criteria were spondylolisthesis, axial skeletal inflammation or osteoarthritis, collagenosis, osteoporosis, spinal surgery, neuromuscular disease, lower limb musculoskeletal injuries, malignant tumor, hypertension, infection or any other nonmechanical condition, radiculopathy, progressive neurological deficit, myelopathy, herniated lumbar disk, and severe pain (more than 7 on the visual analog pain scale [VAS]). All participants gave their informed, written consent according to a protocol approved by the Universit du Qubec TroisRivires ethics committee.

Experimental Protocol
The study participants were tested during 1 session of approximately 60 minutes in the laboratory. Before the experimental task, they completed the following questionnaires: the modified Oswestry questionnaire, the fear avoidance belief questionnaire (FABQ), and VAS (Table 1). AVAS score was also obtained after the experimental task to evaluate if any pain developed during the experimental session. Participants were then asked to perform a trunk flexion-extension task. Verbal instructions, followed by a demonstration and practice trials, were provided before the experiment. From an upright standing position with arms crossed over their chest, participants were instructed to bend forward as far as possible during a 5-second movement period (flexion phase). Then, they were required to hold the fully flexed position for a 3-second period and to return to the initial upright position. The extension phase lasted 5 seconds. Speed and duration of all the movement phases were standardized with a metronome. Five (5) flexionextension cycles were completed by each participant. Afterward, the experimental group (n = 13; 8 men and 5 women) received a lumbar spinal manipulation applied to the middle lumbar segments. The participants were placed on the chiropractic table on their left side. Their trunk was slightly rotated to the right with arms crossed over the chest. The left lower limb was extended, whereas the right leg and thigh were flexed to 90 angle. The chiropractor faced the participants at approximately 45, stabilizing the subjects' right leg between the thighs and the trunk with his right hand. The chiropractor's fingers (left) made contact at the lateral margin of the L3 spinous process, and an impulse thrust with a lateral to medial vector was applied to the vertebral segment. This procedure has been described as spinous pull by

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Table 1. Baseline characteristics of the experimental and control

groups
Experimental group (n = 13) Age (y) Weight (kg) Height (m) Body mass index (kg/m2) LBP duration (n) 1: b1 y 2: 1-3 y 3: 3-5 y 4: 5-10 y 5: N10 y mODI (/100) FABQ F1 (/42) FABQ F2 (/24) VAS before (/100) VAS after (/100) 36.1 12.3 77.1 17.4 1.73 0.12 25.6 3.7 1 4 3 2 3 19.2 10.1 16.1 9.8 8.1 4.4 26.9 21.8 24.9 22.3 Control group (n = 14) 43.5 10.5 72.4 16.5 1.68 0.10 25.3 3.8 2 2 3 4 3 15.6 8.9 11.9 8.5 7.6 6.3 23.3 21.8 30.1 26.9

sandpaper (3M Red Dot Trace Prep), and wiping it with alcohol swabs. The EMG activity was recorded with a Bortec biomedical acquisition system (Model AMT-8, common mode rejection ratio of 115 dB at 60 Hz, input impedance of 10 G) and sampled at 900 Hz with a 12-bit A/D converter (PCI 6024E, National Instruments, Austin, TX). The EMG data were digitally filtered by a 10- to 450-Hz band-pass, zero-lag, fourth-order Butterworth filter. The data were collected by LabView (National Instruments) and processed by MatLab (Mathworks, Natick, MA).

Data Analysis
Rectified EMG signals and kinematics data were plotted to determine total trunk angle corresponding to EMG cessation during the flexion phase and total trunk angle of EMG onset during the extension phase. The EMG cessation and onset were quantified by visual inspection of the rectified EMG signal. The normalized RMS value (normalized to the RMS value in extension during the first trial) during each phase of movement was calculated. The EMG data obtained from the left and right sides were averaged at each level (L2 and L5). Dependent variables included (1) average total trunk flexion angle corresponding to the onset and cessation of myoelectric silence of the FRP; (2) average, normalized EMG amplitude signals (RMS) during the full flexion phase of movement; and finally, (3) the average flexion-relaxation ratio,22 calculated by dividing RMS activity during the flexion phase by RMS of the full flexion phase.

FABQ F1 indicates fear-avoidance beliefs about work; FABQ F2, fearavoidance beliefs about physical activity; mODI, modified Oswestry disability index.

Bergman et al20 and was chosen mainly for technical reason to avoid any displacement of data acquisition instrumentation. All spinal manipulations were performed by an experienced chiropractor blinded to the study objectives and experimental conditions. Participants from the control group (n = 14; 6 men and 8 women) were positioned in a same left-sidelying posture, with the superior knee flexed and the trunk slightly rotated for 10 seconds, but no spinal manipulation was given. Immediately after the spinal manipulation or control position conditions, all subjects performed a second block of 5 trunk flexion-extension tasks. The total time between the spinal manipulation (or control position) and the beginning of the second block of flexionextension trials was between 15 and 45 seconds.

Statistical Analysis
T tests for independent samples were used to evaluate mean differences in baseline characteristics between the groups. Total flexion angle corresponding to the onset and cessation of myoelectric silence, the normalized EMG value during the full flexion phase of movement, and the FRR were compared across different experimental conditions by 2 2 (group condition) repeated-measures analysis of variance (ANOVA). Whenever a group condition interaction was observed, post hoc comparisons were made by Tukey test. For all analyses, statistical significance was set at P b .05.

Instrumentation
Kinematics data were collected by a motion analysis system (Optotrak Certus, Northern Digital, Waterloo, ON, Canada). Light-emitting diodes were positioned on the right side of each participant on the following anatomical landmarks: (a) lateral malleolus, (b) lateral part of the knee, (c) greater trochanter, (d) middle of the iliac crest, (e) lateral part of the 10th rib, and (f) the acromion. The kinematics data were recorded at 100 Hz and low-passfiltered by a dual-pass, fourth-order Butterworth filter with a cutoff frequency at 5 Hz. Surface EMG data were collected by bipolar disposable surface Ag-AgCl electrodes applied bilaterally at the ES at L2 and L5. A ground electrode was placed over the subjects' left acromion. Electrodes were positioned in the muscle fiber direction, according to the model of Merletti et al,21 and skin impedance was reduced by (1) shaving excess body hair, if necessary, and (2) gently abrading the skin with a fine-grade

RESULTS
Baseline control and experimental group characteristics, including age, weight, height, body mass index, pain scores, Oswestry scores, and FABQ scores, were similar in both groups (independent sample t test; P N .05) (Table 1). Pain scores between and after the experimental session were also similar. Repeated-measures ANOVA yielded no significant differences between groups (P N .05), conditions, or interaction effects for the onset and cessation angles of the FRP (L2 and

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Table 2. Mean (SEM) onset and cessation angles of the FRP at L2

and L5 levels before and after spinal manipulation (experimental group) or control position (control group) conditions
Experimental group L2 onset angles Before After L2 cessation angles Before After L5 onset angles Before After L5 cessation angles Before After 81.3 (6.4) 84.0 (6.4) 92.5 (4.7) 94.6 (5.5) 82.5 (4.8) 80.0 (6.2) 93.2 (4.8) 93.4 (5.6) Control group 69.1 (6.4) 65.7 (6.4) 82.5 (4.5) 79.4 (5.2) 73.8 (4.8) 69.6 (6.2) 83.8 (4.6) 81.7 (5.4)

Angles are expressed in degrees.

Fig 2. Mean FRR at L2 (A) and L5 (B) for both groups. The FRR
before and after lumbar spine manipulation of the experimental group (black) and after the side-lying position of the control group (gray).

spine manipulation compared to the control group. No significant (P N .05) group, condition, or interaction effect was seen at the L5 level. Figure 1 illustrates the normalized RMS mean values at L2 and L5 for both groups. Finally, a statistically significant group condition interaction (P = .008) was also noted for the FRR. Indeed, the group that received lumbar spine manipulation presented a significantly increased (Tukey honestly significant difference test; P = .007) postmanipulation FRR, whereas the control group ratio did not vary after the side-lying control position. Figure 2 illustrates the mean FRR at L2 and L5 for both groups.

Fig 1. Normalized RMS mean values at L2 (A) and L5 (B) for both
groups. The RMS values before and after lumbar spine manipulation for the experimental group (black) and after the side-lying position for the control group (gray).

DISCUSSION
Data from this study indicate a reduction of EMG activity during maximal trunk flexion (relaxation phase of the FRP) at the L2 ES level immediately after spinal manipulation at L3 and are in accordance with the preliminary findings of DeVocht et al.19 DeVocht et al19 investigated the effects of spinal manipulation (diversified and activator) on resting EMG levels in 16 chiropractic patients with LBP. The EMG activity was recorded at the 2 tightest muscle bundles in the paraspinal musculature evaluated by palpation. Continuous recording (5-10 minutes) showed a 25% decrease in resting EMG activity in 24 of 31 monitored sites after treatment. Results of this study are also consistent with the observations

L5). Mean onset and cessation angles are presented in Table 2. Normalized RMS values during the full flexion phase were compared across groups and conditions at both L2 and L5, and repeated-measures ANOVA yielded a significant group conditions interaction (P = .02) for the L2 level. A significant post hoc analysis indicated that the experimental group had a significant reduction (Tukey test; P = .008) of EMG activity at the L2 level after lumbar

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of Lehman et al,23 who examined the effects of spinal manipulation on lumbar range of motion and surface paraspinal EMG activity (T9 and L3 levels) in subjects with nonspecific LBP. They reported a decrease in EMG activity of ES muscles in 5 of 14 subjects in full trunk flexion (FRP) after lumbar spine manipulation. Although the authors looked at the flexion-relaxation response, the main objective of their research was to determine the influence of spinal manipulation on trunk kinematics and associated myoelectric activity, and therefore, their experimental design may not have been optimal to detect FRP changes. A theoretical model has been developed by Pickar18 to describe the relationship between pain, spinal manipulation, segmental biomechanics, and the nervous system. According to this model, tissue overload can originate from segmental biomechanical alterations and will result in modifications of the signaling properties of paraspinal mechanoreceptors, in changes in central processing, and ultimately, in efferent somatomotor activity. Spinal manipulation, theoretically, could modulate the inflow of sensory signals from paraspinal structures in a manner that improves physiological functions (effect on EMG paraspinal activity). Indeed, experimental results published by Indahl et al24 suggested that the clinical action of lumbar spine manipulation could result from the inhibitory effect of capsular distension on paraspinal muscle activity. They studied paraspinal muscle motor unit responses to electrical stimulation of the L3-L4 intervertebral disk before and after the introduction of physiological saline solution into porcine lumbar zygapophysial joints. Their data revealed an immediate and constant reduction in motor unit action potential amplitude, within 30 seconds of physiological saline injection. A gradual decline over a 30minute period, or a delayed reaction during which the decrease occurred 5 minutes after injection, was also observed in some animals. This model has not been validated in human subjects, but such mechanisms could very well explain our findings. Interestingly, changes in surface EMG amplitude (RMS) after lumbar spine manipulation only occurred at the L2 level, perhaps representing a local response to a mechanical stimulus of zygapophysial joint. Indeed, Holm et al25 presented data showing that the stimulation of the zygapophysial joint capsule induced reactions predominantly on the same side and segmental level as the stimulation. Holm et al25 also showed, in a feline model, that mechanical stimulation of the posterior ligaments yielded a strong EMG activity at L4 to L5 (point of stimulation) with simultaneous activity in the 3 levels above (L1-L2, L2-L3, and L3-L4) and one level below (L5-L6). Conclusions regarding segmental responses to lumbar spine manipulation are limited because in vivo measurements of segmental capsule and ligament stretch and sites of cavitations were not determined in the experimental paradigm. In this study, spinal manipulation modified ES activity during full trunk flexion, but kinematics parameters of the

FRP, such as onset and cessation angle, were not affected. In healthy individuals, lumbar-pelvic rhythm has considerable intersubject variability. 26,27 Moreover, discrimination between normal and LBP subjects, based on examination of lumbar-pelvic rhythm, has not proven to be reliable.28 Further experiments with additional kinematic markers on the lumbar and pelvic regions could yield interesting information on the effects of spinal manipulation in lumbar-pelvic rhythm and segmental kinematics. A few other studies examined the impact of a therapeutic intervention on the FRP in LBP subjects. Neblett et al29 assessed the influence of a 7-week rehabilitation program on FRP parameters. The program consisted of supervised, progressive exercises combined with education and counseling sessions about pain and stress management. Moreover, patients were trained, by sEMG biofeedback, to relax their back during a trunk flexion task. At the beginning of the experiment, 30% of subjects presented a normal FRP, whereas 94% of them reached a normal response after treatment. Ritvanen et al30 also explored the effects of spinal mobilization/manipulation on the lumbar FRP, compared to those of physiotherapy. Subjects with LBP were tested before and a month after a 2-week intervention (5 treatments). The results were not conclusive; both groups showed a reduction of the FRR caused by an increase in EMG activity during full flexion. The authors explained these findings by the fact that they only retested subjects a month after the end of the intervention when the possible positive impact of treatment may have already decreased. Finally, a study involving a 12-week Swiss ball exercise program was conducted by Marshall and Murphy.31 The data revealed progressive improvements in the FRR during the first 8 weeks of the program. At that point, the patients had reached maximal improvement, and no further significant changes were noted at the 12-week evaluation. Moreover, 3 months after the program ended, a deterioration of the FRP, consisting of a decreased FRR, was reported. Based on the findings of these studies, one could conclude that absence of the FRP in CLBP represents functional and seemingly persistent adaptation to chronic pain.

Limitations
Because our study deployed sEMG instrumentation, deep muscle contribution to the flexion-relaxation response as well as the effect of spinal manipulation on these muscles could not be assessed. Considering that a previous investigation of deep lumbar muscle activity during a flexion-extension task showed activation of the quadratus lumborum and deep lateral lumbar ES during peak lumbar flexion32 and considering that deep muscles are believed to play an important role in lumbar spine stabilization,33,34 future research should focus on the influence of spinal manipulation on deep lumbar muscle-stabilizing mechanisms using intramuscular recording protocols. Furthermore,

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because of technical considerations, the amount of force generated during spinal manipulation was not measured, and systematic recordings of thrust force or controlled force intervention should be undertaken in future experiments. Finally, it was chosen to use a similar SMT procedure for all subjects without regard to their clinical presentation. Using a different SMT procedure may have yielded different results, but considering the current knowledge about SMT biomechanical 15 and neurophysiological effects, 18 we believe that applying similar forces while using different SMT procedures in the lumbar region would not have produced a significantly different effect. According to Hawk et al,35 the lack of a definitive, single, active agent in chiropractic care procedures; the impossibility of totally blinding clinicians administering treatments; and the difficulty in blinding patients represent a real challenge in the design and performance of placebocontrolled spinal manipulation studies . Such challenges are also present in laboratory experiments. The elaboration of a credible placebo would be important in the perspective of exploring FRP parameters together with subjective parameters such as pain and perceived disabilities.

REFERENCES
1. Ekman M, Janhagen S, Hunsche E, Jansson L. Burden of illness of chronic low back pain in Sweden: a cross-sectional, retrospective study in primary care setting. Spine 2005;30: 1777-85. 2. Krismer M, Van Tulder M, The Low Back Pain Group of the Bone and Joint Health Strategies for Europe Project. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific). Best Pract Res Clin Rheumatol 2007;21:77-91. 3. Gutpa A. Analyses of myo-electrical silence of erectors spinae. J Biomech 2001;34:491-6. 4. Floyd WF, Silver PH. Function of erectores spinae in flexion of the trunk. Lancet 1951;1:133-4. 5. Colloca CJ, Hinrichs RN. The biomechanical and clinical significance of the lumbar erector spinae flexion-relaxation phenomenon: a review of literature. J Manipul Physiol Ther 2005;28:623-31. 6. Geisser ME, Haig AJ, Wallbom AS, Wiggert EA. Pain-related fear, lumbar flexion, and dynamic EMG among persons with chronic musculoskeletal low back pain. Clin J Pain 2004;20: 61-9. 7. Sarti MA, Lison JF, Monfort M, Fuster MA. Response of the flexion-relaxation phenomenon relative to the lumbar motion to load and speed. Spine 2001;26:E421-6. 8. Triano JJ, Schultz AB. Correlation of objective measure of trunk motion and muscle function with low-back disability ratings. Spine 1987;12:561-5. 9. Lund JP, Donga R, Widmer CG, Stohler CS. The painadaptation model: a discussion of the relationship between chronic musculoskeletal pain and motor activity. Can J Physiol Pharmacol 1991;69:683-94. 10. Sihvonen T. Flexion relaxation of the hamstring muscles during lumbar-pelvic rhythm. Arch Phys Med Rehabil 1997;78: 486-90. 11. Descarreaux M, Lafond D, Jeffrey-Gauthier R, Centomo H, Cantin V. Changes in the flexion relaxation response induced by lumbar muscle fatigue. BMC Musculoskeletal Disorders 2008;9:0. 12. Olson MW, Li L, Solomonow M. Flexion-relaxation response to cyclic lumbar flexion. Clin Biomech (Bristol, Avon) 2004; 19:769-76. 13. Olson M, Solomonow M, Li L. Flexion-relaxation response to gravity. J Biomech 2006;39:2545-54. 14. Coulter ID, Shekelle PG. Chiropractic in North America: a descriptive analysis. J Manipulative Physiol Ther 2005;28: 83-9. 15. Ianuzzi A, Khalsa PS. Comparison of human lumbar facet joint capsule strains during simulated high-velocity, low-amplitude spinal manipulation versus physiological motions. Spine J 2005;5:277-90. 16. Krekoukias G, Petty NJ, Cheek L. Comparison of surface electromyographic activity of erector spinae before and after the application of central posteroanterior mobilisation on the lumbar spine. J Electromyogr Kinesiol 2007 [in press]. 17. Cramer G, Budgell B, Henderson C, Khalsa P, Pickar JG. Basic science research related to chiropractic spinal adjusting: the state of the art and recommendations revisited. J manipul Physiol Ther 2006;29:726-61. 18. Pickar JG. Neurophysiological effects of spinal manipulation. Spine J 2002;2:357-71. 19. DeVocht JW, Pickar JG, Wilder DG. Spinal manipulation alters electromyographic activity of paraspinal muscles: a descriptive study. J Manipul Physiol Ther 2005;28:465-71.

CONCLUSION
Basic science research is essential for the chiropractic profession. Over the past decades, fundamental research in biomechanics and neurophysiology has shed some light on the possible biological processes underlying the clinical effects of manual therapies and, more specifically, spinal manipulation. This study shows that lumbar spine manipulation can, at least for a brief period, modulate stabilizing neuromuscular responses of the lumbar spine in a group of patients with LBP. Further investigations are needed to assess the long-term impact of lumbar spine manipulation on neuromuscular responses and to evaluate the correlation between neuromuscular changes observed after lumbar spine manipulation and alterations in pain disability scores after repeated treatments.

Practical Applications
The FRP onset and cessation angles did not differ across groups or conditions. Lumbar spine manipulation decreased EMG activity during maximal trunk flexion (relaxation phase) at L2. Lumbar spine manipulation increased extensionrelaxation ratio at L2. Lumbar spine manipulation may temporarily modulate stabilizing neuromuscular responses of the lumbar spine during trunk flexion and extension.

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20. Bergmann TF, Peterson DH, Lawrence DJ. Chiropractic technique. New York: Churchill Livingstone; 1993. p. 803. 21. Merletti R, Lo Conte L, Avignone E, Guglielminotti P. Modeling of surface myoelectric signalspart I: model implementation. IEEE Trans Biomed Eng 1999;46:810-20. 22. Watson PJ, Booker CK, Main CJ, Chen AC. Surface electromyography in the identification of chronic low back pain patients: the development of the flexion relaxation ratio. Clin Biomech (Bristol, Avon) 1997;12:165-71. 23. Lehman GJ, Vernon H, McGill SM. Effects of a mechanical pain stimulus on erector spinae activity before and after a spinal manipulation in patients with back pain: a preliminary investigation. J Manipulative Physiol Ther 2001;24: 402-6. 24. Indahl A, Kaigle AM, Reikeras O, Holm SH. Interaction between the porcine lumbar intervertebral disc, zygapophysial joints, and paraspinal muscles. Spine 1997;22:2834-40. 25. Holm S, Indahl A, Solomonow M. Sensorimotor control of the spine. J Electromyogr Kinesiol 2002;12:219-34. 26. Nelson JM, Walmsley RP, Stevenson JM. Relative lumbar and pelvic motion during loaded spinal flexion/extension. Spine 1995;20:199-204. 27. Pal P, Milosavljevic S, Sole G, Johnson G. Hip and lumbar continuous motion characteristics during flexion and return in young healthy males. Eur Spine J 2007;16:741-7. 28. Lariviere C, Gagnon D, Loisel P. The effect of load on the coordination of the trunk for subjects with and without chronic

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