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Recurrence And Features Of Recruitment; Is It Coming Back Round?

A recent systematic review (Devecchi et al., 2021) explored the evidence related to characteristics associated to movement and recurrent low back (LBP) and neck pain (NP). Studies considering individuals in periods of remission compared to those without a history of pain were explored.

Check the label

To the authors’ credit, rather than labelling the changes as ‘dysfunctional, aberrant, or even atypical’ the term ‘neuromuscular adaptions’ was employed to describe a range of features to include muscle activity, kinematics, muscle properties, and sensorimotor control; literature highlights these features may contribute to not only pain but also recurrence (Hodges et al., 2011, 2015; van Dieen et al., 2017).

In the acute presence of pain, muscle activity, spinal kinematics, and sensorimotor control ‘adaptations’ have been observed (Falla et al., 2008; Falla & Hodges, 2017; van Dieen et al., 2003, 2019). Such changes may persist in the wake of pain and subsequently influence pain’s return (recurrence; Hodges 2011; Hodges et al., 2009; Macdonald et al., 2009).

Something or nothing?

With respect to findings, the review identified very low-level evidence supporting the existence of changes in motor behaviours in during periods of remissions for individuals reporting LBP recurrence. Specifically, these findings included increased muscle co-contraction, muscle synergist activity redistribution, and altered (delayed) onset of deep axial muscles. Additionally, recurrence appears to possess an association to limited sagittal plane ROM. Evidence considering NP was identified as ‘very limited’. In all cases, the authors highlight the need for further insights on the mechanisms corresponding to these observations.

Beyond strength

While clinicians may routinely observe an array of ‘neuromuscular adaptations’ within their patient populations, the existing body of evidence is clearly far from compelling. Evidence-based practice may see the results of the review as a stumbling block; evidence-led practice may see enough of a narrative within the studies as to allow it to aid their patient management.

The review highlights something is happening, yet what research tools or questions are required to make these outcomes overt? An alternative perspective on the paper as a whole, would be to welcome the re-appraisal of the complex interaction of muscles and their synergists (e.g., Hodges et al., 1996) in respect to the bigger picture of human movement. If we are still living in the epoch of ‘can’t go wrong getting strong’ the review may act as an impetus for research to further inform on the subtle, but seemingly real features of clinical scenarios and recurrence.


Devecchi, V., Rushton, A. B., Gallina, A., Heneghan, N. R., & Falla, D. (2021). Are neuromuscular adaptations present in people with recurrent spinal pain during a period of remission? a systematic review. PloS one, 16(4), e0249220.

Falla D, Farina D. Neuromuscular adaptation in experimental and clinical neck pain. J Electromyogr Kinesiol. 2008; 18(2):255–61. PMID: 17196826

Falla D, Hodges PW. Individualized Exercise Interventions for Spinal Pain. Exerc Sport Sci Rev. 2017 Apr; 45(2):105–115. PMID: 28092298

Hodges PW. Pain and motor control: From the laboratory to rehabilitation. J Electromyogr Kinesiol. 2011 Apr; 21(2):220–8. PMID: 21306915.

Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis. Spine (Phila Pa 1976). 1996 Nov 15;21(22):2640–50. PMID: 8961451

Hodges PW, Smeets RJ. Interaction between pain, movement, and physical activity: short-term benefits, long-term consequences, and targets for treatment. Clin J Pain. 2015 Feb; 31(2):97–107. PMID: 24709625

Hodges PW, Tucker K. Moving differently in pain: a new theory to explain the adaptation to pain. Pain. 2011 Mar; 152(3 Suppl):S90–8. PMID: 21087823

Hodges P, van den Hoorn W, Dawson A, Cholewicki J. Changes in the mechanical properties of the trunk in low back pain may be associated with recurrence. J Biomech. 2009 Jan 5; 42(1):61–6. https:// PMID: 19062020

MacDonald D, Moseley GL, Hodges PW. Why do some patients keep hurting their back? Evidence of ongoing back muscle dysfunction during remission from recurrent back pain. Pain. 2009; 142(3):183–8. PMID: 19186001

van Diee¨n JH, Flor H, Hodges PW. Low-Back Pain Patients Learn to Adapt Motor Behavior With Adverse Secondary Consequences. Exerc Sport Sci Rev. 2017 Oct; 45(4):223–229. 1249/JES.0000000000000121 PMID: 28704216

Van Diee¨n Jaap H, Cholewicki JH, Radebold AH. Trunk Muscle Recruitment Patterns in Patients With Low Back Pain Enhance the Stability of the Lumbar Spine. Spine (Phila Pa 1976). 2003; 28(8):834–41. PMID: 12698129

van Diee¨n JH, Reeves NP, Kawchuk G, van Dillen LR HP. Motor Control Changes in Low Back Pain: Divergence in Presentations and Mechanisms. J Orthop Sport Phys Ther. 2019; 49(6):370–9. https:// PMID: 29895230


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