Chapter

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Introduction: convergence and divergence of

opinions on spinal control
Paul W. Hodges*, Jaap H. van Dien and Jacek Cholewicki

*NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, University of
Queensland, Brisbane, Queensland, Australia, MOVE Research Institute Amsterdam, Faculty of Human Movement Sciences, VU University
Amsterdam, Amsterdam, The Netherlands and Department of Osteopathic Surgical Specialties, College of Osteopathic Medicine, Michigan State
University, East Lansing, Michigan, USA

CHAPTER CONTENTS
Models of spine control and experimental
approaches
Motor control
Proprioceptive systems
Spinal control as a basis for design of
clinical treatments for low back and
pelvic pain
Convergence and divergence of opinions
in spine control
References

2
2
3
3
3
4

It is well defended and accepted that control of the spine

and pelvis depends on the contribution of active, passive
and control systems (Panjabi 1992). In this interpretation
of spine physiology, ideal control relies on the appropriate passive support, supplemented with muscle forces
that are coordinated by the nervous system. Conversely,
changes in any of these systems can lead to less than
optimal control and this has formed the basis of a range
of rehabilitation strategies that aim to restore control and
reduce pain and disability or the potential for further
pain or injury. Although the theoretical underpinning is
relatively straightforward, there is variable evidence for
the many assumptions that underlie the understanding of
spine control and the way in which it may be modified
with pain and/or injury or the manner in which aspects
of spine control may be a precursor to development of
pain and/or injury. An area of considerable variation in
opinion is how this model can be applied to clinical
practice for the treatment of people with low back and
pelvic pain.

Low back and pelvic pain is a major issue facing the

modern world. The economic burden of musculoskeletal
pain is second only to cardiovascular disease (Australian
Bureau of Statistics 2001) and of that burden, spinal complaints contribute the greatest percentage due to long-term
disability. Low back pain (LBP) is the most common
chronic pain in Australia (Blyth etal. 2001), and the most
common work-related condition in Western society. Recurrence and persistence of symptoms are major issues in LBP
and are associated with the majority of its health care and
social costs. Persistent LBP is increasing and its prevalence
has doubled in the last 14 years (Freburger etal. 2009).
Although clinical guidelines promote the view that acute
LBP has a favourable prognosis with most people recovered in 6 weeks (Koes etal. 2001), systematic reviews of
prospective trials suggest that 73% of people experience at
least one recurrence in 12 months of an acute episode, and
pain and disability have only recovered by 58% at one
month (Pengel etal. 2003). Further recovery is slow
(Pengel etal. 2003; Henschke etal. 2009). Identification
of modifiable factors associated with LBP is a key objective
in the international research agenda. However, reviews of
risk factors provide less than encouraging results (Linton
2000; Pincus etal. 2002). Even factors that have been
purported to have the strongest relationship to outcome,
such as psychosocial aspects of distress (Pincus etal.
2002) and job satisfaction (Linton 2000), can only account
for a small proportion of the variability (Linton 2000;
Young Casey etal. 2008). There is no evidence for an
association between biological factors such as trunk
muscle strength or endurance, or range of motion and LBP
outcome (Hamberg-van Reenen etal. 2007). However, in
clinical practice and many fields of research, it has been
proposed that spine control is related to low back and

Spinal Control: The rehabilitation of back pain

pelvic pain and investigation of this promising notion is
worthy of a concerted research effort.
There are considerable promising data of changes in
spine control as a potential candidate factor underpinning
the development and persistence of low back and pelvic
pain from cross-sectional studies (Hodges and Richardson
1996; MacDonald etal. 2009) and some longitudinal
studies (Cholewicki etal. 2005). Positive outcomes from
clinical trials, that have been summarized and subjected
to meta-analyses in a number of systematic reviews (Ferreira etal. 2006; Macedo etal. 2009), provide additional
strength to the argument that consideration of spine
control in the management of low back and pelvic pain
is worthwhile and promising.
The counter argument is that biological aspects are less
important than psychosocial aspects of pain, and that
compromised spine control may be present but neither
sufficient nor necessary for the perpetuation of pain. Criticism of the biological model of pain has come from a
number of sources. For instance, the lack of a one-to-one
relationship between indications of structural damage on
diagnostic imaging and pain is commonly used as an argument against the importance of mechanical injury in its
origin. However, such argumentation could be used similarly to deny the relation between smoking and lung
cancer; not every person with lung cancer is or was a
smoker, nor does every smoker develop lung cancer. A
probabilistic model is more appropriate here and structural abnormalities are strong risk factors for LBP.
Current evidence suggests we cannot reject the contribution of biological issues to development and persistence
of pain. The quality of spine control which determines
the nature and magnitude of loading on spinal structures
is likely to be a key factor in this equation. However,
within the consideration of spine control there are different interpretations and opinions. There are differing opinions regarding the most appropriate theoretical models to
understand the systems; this extends to biomechanical/
engineering models, neurophysiological models of control
of motor output and sensory input, and clinical models
extrapolating from research and clinical practice to formulate effective treatments for back pain. This book aims to
provide a state-of-the-art review of the current understanding of these issues, the areas where opinions converge and
diverge, and a road map for consideration of how to
resolve the critical questions in the field.

MODELS OF SPINE CONTROL AND

EXPERIMENTAL APPROACHES
There are fundamental differences in how people define
and model spine control leading to different interpretations of what is optimal. Although early models relied on
static methods, more recent approaches propose dynamic

models and consideration of systems engineering aimed

at understanding the mechanisms by which the spine is
controlled to meet the demands of everyday activities. A
key issue is that different models rely on different assumptions and lead to different conclusions about the optimal
mechanisms for spine control and about the consequences
of changes in control for the health of the system and,
therefore, lead to different extrapolations from science to
clinical practice. The first part of this book (Chapters 24)
takes a look at the state-of-the-art research in terms of
modelling and novel experimental approaches that aim to
provide insight into the mechanisms for control of this
complex system.

MOTOR CONTROL
Motor control is a term that can be used to refer to all
aspects of control of movement. This can extend from the
motivation within the frontal and other regions of the
brain related to the decision to move, the sensory inputs
to the system that provide information of the body segments current location and movement, the various levels
of the nervous system that integrate inputs and plan
outputs (from simple spinal cord mechanisms to complex
supraspinal integration and decision making), the motor
output to the muscles (the effector organs of the system),
and down to the mechanical properties of the tissues
(including muscle mechanics and passive tissues that
influence joint mechanics) that influence the manner in
which motor commands to muscles relate to movement.
There are many views of how consideration of motor
control can be applied to the issue of spine control, and
how the nervous system meets the challenge to control the
spine and pelvis when considered in the context of the
entire human body function. Drawing on the developments in modelling of spine biomechanics highlighted in
Chapters 24, this view of spine control involves not only
control of the spine movement and position that is specific
to the demands of the task, but also the contribution of
the spine to other physiological functions such as breathing and maintaining whole body equilibrium, to name
but a few functions that the nervous system must consider
concurrently.
Perhaps the most debated aspect of motor control, as it
relates to spine control, is how and why motor control is
altered in people with pain and injury. Fundamental questions remain unresolved. Are there issues in motor control
that can predispose an individual to development of pain
and/or injury? Does motor control adapt in response to
pain and injury or is this a factor in the persistence and
recurrence of pain? Which aspects of motor control are the
most critical for low back and pelvic pain, if at all? Which
aspects of motor control, if any, should be addressed in
patients with low back and pelvic pain? Part 2 of this book

Introduction: convergence and divergence of opinions on spinal control

(Chapters 511) tackles these fundamental issues to
provide a comprehensive view of the current state of
knowledge.

PROPRIOCEPTIVE SYSTEMS
Although sensation is a critical element of motor control,
there are issues related to sensory function that require
specific consideration. Deficits in proprioception have
been described for many conditions related to pain and
injury in the musculoskeletal system. From deficits in the
acuity to detect input (Lee etal. 2010), to changes in the
organization of cortical areas associated with sensory function (Flor etal. 1997). A glaring issue in the low back and
pelvic pain literature is why do some studies report differences in sensory function between patients with low back
pain and healthy control subjects, whereas others do not?
This could be explained by many reasons: differences
between patient subgroups, differences between specific
parameters of sensory function that have been studied,
or other methodological issues (e.g. sample size and
reliability/validity of measures). Resolution of this issue
and other issues (such as the question of which sources of
sensory information are used in the control of the spine,
and how this is used) requires deeper understanding of
sensory function as it relates to the spine and pelvis. Any
extrapolation from research to clinical practice necessitates
an understanding of the state-of-the-art of this field. This
discussion forms the basis of Part 3 (Chapters 1214).

SPINAL CONTROL AS A BASIS FOR

DESIGN OF CLINICAL TREATMENTS
FOR LOW BACK AND PELVIC PAIN
Perhaps the biggest point of apparent divergence of
opinion arises when the findings of research and the
observations from clinical practice are translated into
clinical interventions for the management of low back and
pelvic pain. Many clinical programs have been proposed.
On the surface, these approaches have often been viewed
as divergent and the unique aspects of each are often
emphasized to amplify points of difference. But how different are they really? Do they share a common foundation with some specific distinctions based on different
interpretations of the literature and clinical observations?
Or are they diametrically opposed, mutually exclusive and
incapable of being amalgamated into a single broader
approach? The debate has often been fuelled by presentation of simplified/reductionist views of an approach to a
single element (e.g. activation of deep abdominal muscles
in a lying position) rather than presentation of an entire
concept, and work that misinterprets the literature and

Chapter

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perpetuates misunderstanding of the scope of some phenomena (e.g. Levin 2002; Lederman 2010). In some ways
it may be considered that the indirect debate and criticism
within the field is its own worst enemy.
We have reached a critical point in time at which it is
necessary to consider where the divergence and convergence of opinions lie in order to move the field forward.
Points of convergence require clarification and where
divergence remains, studies must be planned to test the
relative merits of the different ideas. It is possible that one
hypothesis is correct, that several are correct (but it
depends on the individual patient as to which alternative
approach applies to them) or the research may lead to
generation of new hypotheses.
A major aim of this book is to present the arguments
and consider the areas for divergence and convergence in
opinions. The state-of-the-art evidence on efficacy of exercise interventions for low back and pelvic pain is outlined
in Part 4 (Chapter 15), whereas the foundations for different clinical ideas is presented throughout Chapters
214 with references to research and the justification for
the extrapolations that have been made from basic science
to clinical practice.

CONVERGENCE AND DIVERGENCE

OF OPINIONS IN SPINE CONTROL
The chapters that make up Part 5 (Chapters 1620) forge
new territory in the debate regarding spine control and its
relevance for low back and pelvic pain. These chapters are
prepared by collaboration between key players in each
area of consideration in the book, and draw the line
between the convergence and divergence of viewpoints.
These five chapters help resolve some of the misunderstanding within the field and provide a unique insight into
what is known, what is unknown and what are the priorities for the future. Key issues that are addressed include:
1. Biomechanical modelling and engineering
approaches provide considerable promise to
understand the relevance of spine control to low
back and pelvic pain. But can this information be
used to understand the individual patient and design
treatment? Chapter 16 considers this and other areas
of convergence and divergence of opinion in
modelling of spinal control.
2. Multiple groups are working on the challenge to
subgroup individuals with low back and pelvic pain
for the targeting of interventions (Chapter 17).
Although this approach is logical, different
approaches exist, it cannot a priori be assumed that
subgrouping improves outcomes, and there are many
pitfalls and challenges for the development of
clinical methods and the subsequent validation of
these approaches.

Spinal Control: The rehabilitation of back pain

3. Whether differences in motor control between

patients and healthy controls are a cause or

consequence of low back and pelvic pain requires
consideration (Chapter 18). This is not a trivial
question to resolve as it requires complex
experimental methods, and the fact that changes in
motor control could be either, neither or both cause
and consequence.
4. If and how sensory function is affected in low back
pain and injury, if this is relevant for development or
persistence of symptoms, and how this could be
addressed in low back and pelvic pain is far from
resolved. This issue is debated in Chapter 19.
5. An issue of considerable discussion in the literature
and a topic of surprising convergence of
fundamental concepts but also considerable
divergence of opinions is how experimental and

clinical observations can be extrapolated to effective

clinical interventions. Chapter 20 makes a major
contribution by highlighting where the views
converge and diverge and presents a road map for
how to progress knowledge in this sometimescontentious issue.
Finally, Part 6 of the book (Chapter 21) highlights all that
has been gained from identification of the state-of-the-art
of understanding across the field of spine control and
discusses ways that this has been applied to the design and
implementation of treatment for people with low back
and pelvic pain. The result is a multifaceted approach to
optimization of motor control that considers individual
differences within a multi-dimensional framework that
includes consideration of the bio-psycho-social model
of pain.

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