SPINE Volume 38, Number 15, pp 1260-1267

Spine ©2013, Lippincott Williams & Wilkins

BlOMECHANICS

Comparison of Lumbopelvic Rhythm

and Flexion-Relaxation Response Between 2
Different Low Back Pain Subtypes
Min-hee Kim, PhD, PT,* Chung-hwi Yi, PhD, PT,t Oh-yun Kwon, PhD, PT,t Sang-hyun Cho, PhD, MD,t
Heon-seock Cynn, PhD, PT,tYoung-ho Kim, PhD,t Seon-hong Hwang, PhD,* Bo-ram Choi, PhD, PT,*
ji-a Hong, MSc, PT,* and Doh-heon Jung, BHSc, PT§

response of the erector spinae muscle disappeared in the LFRS and

Study Design. A cross-sectional study to compare the kinematics
LFRS LBP subgroups.
and muscle activities during trunk flexion and return task in people
Conclusion. These results show that the lumbopelvic rhythms are
with and without low back pain (LBP).
different among healthy subjects and patients assigned to 2 specific
Objective. To characterize the lumbopelvic rhythms during trunk
LBP subgroups. These results provide information on the FR response
flexion and return task in a group of healthy persons and 2 different
of the erector spinae muscle.
subgroups of patients with LBP, identifying the flexion-relaxation
Key words: lumbopelvic rhythm, flexion-relaxation response,
(FR) responses in each group.
lumbar flexion with rotation syndrome, lumbar extension with
Summary of Background Data. The lumbopelvic rhythm is the
rotation syndrome, low back pain.
coordinated movement of the lumbar spine and hip during trunk
Level of Evidence: N/A
flexion and return and is a clinical sign of LBP. However, the reported
Spine 2013;38:1260-1267
patterns of lumbopelvic rhythm in patients with LBP are inconsistent,
possibly because previous studies have examined a heterogeneous
group of patients with LBP. To clarify the lumbopelvic rhythm

patterns, it is necessary to study more homogeneous subgroups of
patients with LBP
Methods. The study involved the following subjects: control group
of healthy subjects (N = 16); lumbar flexion with rotation syndrome
(LFRS) LBP subgroup (N = 1 7); and lumbar extension with rotation
syndrome (LERS) LBP subgroup (N = 14). The kinematic parameters
during the trunk flexion and return task were recorded using a
3-dimensional motion capture system, and the FR ratio of the erector
spinae muscle was measured.
Results. The flexion angle of the lumbar spine was larger in
the LFRS subgroup than in the control group and the LFRS LBP
subgroup, and the hip flexion angle was larger in the LFRS LBP
subgroup than in the control group and LFRS subgroup. The FR
From the *lnstitute of Health Science, Yonsei University, Wonju, Gangwon-
do. Republic of Korea; Departments of tPhysical Therapy and ^Biomédical
Engineering, Yonsei University, Wonju, Cangwon-do, Republic of Korea;
and §Department of Rehabilitation Therapy, The Graduate School, Yonsei
University, Wonju, Gangwon-do, Republic of Korea.
Acknowledgment date; November 13, 2012. First revision date; January 26,
2013. Second revision date; March 2,2013. Acceptance date; March 4,2013.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work.
No relevant financial activities outside the submitted work.
Address correspondence and reprint requests to Chung-hwi Yi, PhD, PT,
Department of Physical Therapy, Yonsei, 1 Yonseidae-gil, Wonju, Gangwon-
do 220-710, Republic of Korea; E-mail: pteagle@yonsei.ac.kr
DOI; 10.1097/BRS.0b013e318291 b502
1260 www.spinejournal.com
L
umbopelvic rhythm is a specifically organized pattern
characterized by coordination of the lumbar region and
hip region connected to the pelvis during trunk flexion
and return.'"^ In previous studies, various patterns of altered
lumbopelvic rhythm have been reported in patients with low
back pain (LBP)/^'' Paquet et aP have shown that lumbar spine
movement during trunk flexion is reduced in people with LBP.
In contrast, Porter and Wilkinson' and Esola et aP reported
that lumbar spine movement was greater in patients with LBP
compared with that in healthy people. The literature on lum-
bar spine and hip movement patterns in people with LBP is
inconsistent, and despite much investigation, the relationship
between LBP and lumbopelvic rhythm remains inconclusive.
Several factors may underlie these inconsistent findings.
Deyo et aP° suggested that inconsistent findings were the
result of studies conducted on a group of subjects with wide
variety of LBP subtypes. Most previous reports have been
conducted in people with a heterogeneous type of LBP, and it
may be difficult to compare lumbar spine and the hip move-
ment patterns among different LBP subtypes. Moreover, the
assessment of lumbopelvic rhythm in people with LBP may
be discordant because of considerable variation in the move-
ment patterns in heterogeneous LBP experimental groups.''•'-
Therefore, several investigators have suggested that studies
conducted in homogeneous subgroups of LBP are necessary
to address these concerns. ""^^'
During the trunk flexion, the eccentric muscle activity of
the erector spinae (ES) increases, and then when lumbar spine
July 2013
 BlOMECHANICS
is fully flexed, the ES muscle activity suddenly
This response, referred to as flexion-relaxation (FR), is a reflex
that allows the ES to deactivate and the passive components
of the spine to produce the extension movement. This specific
response has been reported to occur in the lumbar region of
more than 90% of healthy people who do not have LBR'^"-"
In persons with LBP, the trunk muscle activation pattern is
altered and the lower back muscles are strongly activated dur-
ing a long period.-' It is also necessary to evaluate ER response
in a classified homogeneous subgroup of LBP.
Classification systems to categorize people with LBP into
homogenous subtypes and to establish appropriate treatment
strategies for people with LBP have been proposed.""-' The
movement system impairment classification system, which
uses the kinesiopathological approach, categorizes LBP into
5 subtypes by examining the alignments, movements, and
symptoms associated with LBP.^^ The reliability and construct
validity of the movement system impairment classification
system has been reported to be acceptable.-"^ The lumbar
flexion with rotation syndrome (LERS) and lumbar exten-
sion with rotation syndrome (LERS) subtypes were selected
for this study because these have been reported to be more
common.^^'^' Subjects in the LERS LBP subgroup tend to have
rotation and flexion of the lumbar spine during trunk and
lower extremity movement. These symptoms usually increase
with repeated flexion or axial rotation, and usually decrease
when lumbar flexion or axial rotation motion is restricted.-^"
People in the LERS LBP subgroup tend to have lumbar spine
rotation and extension during trunk and lower extremity
movement. These symptoms usually increase with repeated
extension or axial rotation, and usually decrease when lum-
bar extension or axial rotation movement is restricted and
corrected.'-
The purpose of this study was to compare the lumbopelvic
rhythm and ER response in healthy adults and 2 homogeneous
LBP subgroups. We hypothesized that the lumbopelvic rhythm
and the ER response of the ES muscle would differ between
healthy and LBP groups and between the 2 LBP subgroups.
MATERIALS AND METHODS
Study Design
This study used a comparative cross-sectional design to com-
pare kinematics and muscle activities during trunk flexion
and return task in people with and without LBP.
Subjects
The control group consisted of 16 subjects with no history of
LBP (Table 1). The inclusion criterion for the LBP subgroups
was mechanical LBP without radiating pain. Exclusion crite-
ria for these groups were (1) a history of spinal or leg surgery,
(2) a medical diagnosis of ankylosing spondylitis, (3) a medi-
cal diagnosis of rheumatoid arthritis, (4) a medical diagnosis
of degenerative disease, (5) a medical diagnosis of any other
neurological disorder, or (6) visually fixed kyphosis or sco-
liosis. Seventeen subjects were classified into the LERS LBP
subgroup and 14 were classified into the LERS LBP subgroup.
Spine
Lumhopelvic Rhythm and Flexion-Relaxation Response • Kim et al
TABLE 1 . •nëral Charactenstics of the Subjects
Control LFRS* LERSt
Parameter (N = 16) (N = 17) (N = 14) P
Age (yr) 23.8 ± 2 . 9 23.5 ± 2 . 4 23.8 ± 3.9 0.94
Height (cm) 169.1 ± 8.7 173.3 ± 9.8 169.4 ± 7.0 0.30
Weight (kg) 61.3 ± 9.2 67.2 ± 1 1 . 9 65.0 ±11.2 0.29
P values in the ANOVA
'Lumbar flexion with rotation syndrome,
f Lumbar extension witb rotation syndrome.
SD indicates standard deviation; ANOVA, analysis of variance.
The diagnostic movement tests related to LERS included trunk
flexion or rotation while standing, unilateral or bilateral hip
and knee flexion and hip abduction with lateral rotation in
the supine position, knee flexion or hip rotation in the prone
position, backward rocking in the quadruped position, and
lumbar flexion while sitting. The primary tests were provoca-
tion tests, designed to assess movements or stresses in flexion
and rotation motion. The secondary tests were confirmatory
tests, designed to correct or inhibit the flexion and rotation
motion. If a primary test was positive, a secondary test was
performed. When movements or symptoms were reduced in
the secondary test, the result was confirmed as positive. In this
study, 17 subjects in the LERS LBP group showed positive
results in the primary test for 8 or more items and positive
results in the secondary test for 5 or more items. The diag-
nostic movement tests related to LERS included return from
bending, lateral flexion and trunk rotation in the standing
position, straight leg raise, shoulder flexion to 180°, and hip
abduction with lateral rotation in the supine position, knee
flexion, hip rotation, and hip extension in the prone position,
forward rocking and shoulder flexion in the quadruped posi-
tion, and knee extension in the sitting position. The primary
tests were designed to assess movements or stresses in exten-
sion and rotation motion. The secondary tests were designed
to correct or inhibit the extension and rotation motion.
According to the examinations, LERS LBP subjects had posi-
tive results for 10 or more items in the primary test and 8 or
more items in the secondary test. This study was approved
by the Yonsei University Eaculty of Health Sciences Human
Ethics Committee. The subjects were provided with details of
the experiment and each provided written informed consent
prior to participation.
Testing Protocol
The trunk flexion and return task consisted of relaxed stand-
ing, bending, hanging, returning, and recovery standing
periods (Eigure 1). The subjects were required to stand com-
fortably for 5 seconds (relaxed standing period) and then to
bend forward with their arms dangling freely for 3 seconds
(bending period). The subjects were instructed to hold the
fully flexed position for 3 seconds (hanging period), they
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 BlOMECHANICS
I I
Relaxed standing Bending Hanging Returning
were then instructed to return to the upright position for
3 seconds (returning period), and finally, the subjects were
asked to maintain the return standing position for 5 seconds
(recovery standing period). The mean score of the 3 trials
was used in the kinematic and electromyographical (EMC)
data analysis.
Experimental Apparatus
3-Dimensional Motion Capture System and
Kinematic Parameters
The 3-dimensional motion capture system consisting of 6
infrared cameras (Vicon MX, Oxford Metrics Ltd, Oxford,
UK) was used to record the kinematic data. The kinematic
data were collected using camera sampling at 60 Hz. A
total of 20 retroreflective markers 14 mm in diameter were
attached to the subject's lumbar spine and lower limb using
double-sided adhesive tape as follows: (1) four markers at
the T12 and L2 spinous process and bilaterally 3 cm lateral
from L2 spinous process; and (2) 16 markers on the lower
limb bilaterally: the anterior and posterior superior iliac
spines, lateral femoral epicondyle, midpoint between the
anterior superior iliac spine and lateral femoral epicondyle,
lateral malleolus, midpoint between the lateral femoral epi-
condyle and lateral malleolus, distal head of second meta-
tarsal, and posterior aspect of the calcaneus. All markers
were attached to the skin overlying these bony landmarks.
All trials were processed using Vicon Nexus software (Vicon
MX, Oxford Metrics Ltd). The recorded kinematic data
were filtered using the Woltring filter and calculated using
Vicon Plug-in Gait and a customized BodyLanguage model
(Vicon MX, Oxford Metrics Ltd). The kinematic param-
eters included lumbar and hip flexion angles.^" Lumbar
flexion angle was defined as the y-axis angle between the
lumbar spine segment and the pelvis segment; the lumbar
rotation angle was defined as the z-axis angle. Hip angle in
sagittal plane was defined as the y-axis angle between pelvis
1262 www.spinejournal.com
Lumbopelvic Rhythm and Flexion-Relaxation Response • Kim et al
1 Time
I I Figure 1 . Period definitions for the trunk
Recovery standing flexion and return task.
and femur segment. Each link between segments was set to
a joint coordinate system with the x-axis directed antero-
posteriorly, the y-axis directed mediolaterally, and the .j-axis
directed superoinferiorly.
Surface Electromyography and EMG Parameters
Muscle activity was measured using the Noraxon Telemyo
2400T (Noraxon Inc, Scottsdale, AZ) with a pair of Ag-AgCl
surface electrodes measuring 2 cm in diameter. The electrodes
were applied over both ES muscles at the level of L3-L4 later-
ally 2 cm from the spinous process.^' The reference electrode
was attached to skin overlying the iliac crest. The raw EMG
signals were band-pass filtered between 20 and 450 Hz, sam-
pled at 1000 Hz, and processed using MyoResearch Master
Edition 1.06 XP software (Noraxon Inc). The EMG signals
were processed into the root-mean-square (RMS) moving
window of 300-ms duration of EMC data. The ER ratio (%)
was calculated as the ratio of the RMS activity of the hanging
period to the RMS activity of the bending period.-'^ Mathieu
and Eorin" suggested that if ES muscle activity during hang-
ing period is less than 10% of muscle activity during bending
period, it indicates the presence of ER (ER ratio < 10%). The
ER ratios were measured in the bilateral ES muscles.
Data Collection and Processing
The kinematic data during the bending and returning peri-
ods were interpolated to 101 data points for subsequent divi-
sion into quartiles of 25 points each. The kinematic variables
during the task were investigated by angular displacements
of the lumbar spine and hip joint during the bending and
returning periods. The angular displacements were statisti-
cally analyzed in quartiles of 25% time intervals in bending
and returning period (Eigure 1). Also, the EMG data collected
during the trunk flexion and return task were analyzed and
reported using MyoResearch Master Edition 1.06 XP soft-
ware (Noraxon Inc). The ER ratio was calculated by dividing
the RMS value during the 3 seconds of hanging period by
July 2013
 BlOMECHANirS Lumbopelvic Rhythm and Flexion-Relaxation Response • Kim et al

Lun^ïara<igte

IQO 0 50 7S 100

(B) 70
/u •
70

eo ' 60

50 • SO

40 • «3

A
30 • 3Q '

20 <
/y' •&

10 • IQ

0' * O
7S 100 ?5 100

! Uimbir angl*

60

40 '
- \
30'

3D '

10'

n
25 100

Figure 2. Averaged flexion movement of the lumbar spine and hip. (A) Control group. (B) Lumbar flexion with rotation syndrome LBP subgroup.
(C) Lumbar extension with rotation syndrome LBP subgroup. The x-axis represents the normalized time (%) and the y-axis represents the flexion
angle (°). LBP indicates low back pain.

the RMS value during the 3 seconds of hending period and
multiplying by 100.^^
Statistical Analysis
The SPSS software (version 14; SPSS, Inc, Chicago, IL) was used
to detect differences among the 3 groups using a 1-way analysis
of variance (ANOVA). Tukey correction was used when making
multiple comparisons. A paired t test was used to test differences
in measured data between the right and left side in each group.
The results are expressed as the mean ± SD, and P values less
than 0.05 were deemed to be statistically significant.
Spine
RESULTS
Only the data from the right side were analyzed because
there was no significant difference between the right and left
sides (P > 0.05). The continuous movement trajectories of
the lumbar spine and hip in the control group revealed the
normal lumbopelvic rhythm (Figure 2A). Indeed, the lum-
bopelvic rhythm in healthy subjects showed that the lumbar
spine motion was dominant in the early stage of the bending
period and that hip joint motion was dominant in the final
stage. This rhythm is reversed during the returning period, so
that hip extension is dominant early, and lumbar extension
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Spine BlOMECHANICS Lumbopelvic Rhythm and Flexion-Relaxation Response • Kim et al

TABL E ¿. of * ' lÄBLt J. ¡Kiiges (Mean '± SD in Degf'SfoT''^

I^PLumbar and Hip Flexion Angles ^Lumbar and Hip Flexion Angles at
at Each Quartile D u r i n ^ h ^ e n d i n ^ . ach Ouartile Durins the Returning

Quartile
ä
i
é
Period
Control LFRS
jHn^^^^^H
LERS P
j^^K. ^ »Period : | ^ ^ ^ H | | ^ ^ ^ ^ H H H I I I Í H H
Quartile Control LFRS LERS P
Lumbar flexion angle Lumbar flexion angle

1st 9. 6 ±2.6 11.2 ±3.3 9.9 ± 2.2 0.210 1st 6.7 ± 1.8 7.8 ± 3.9 6.0 ± 1.7 0.205
2nd 20.0 ± 3.8 20.1 ± 4.9 16.3 ±2.5*t 0.017
2nd 20.0 ± 5.2 22.1 ± 4 4 19.3 ±4.1 0.217
3rd 16.7 ±4.2 18.5 ±4.7 15.7 ±2.9 0.160
3rd 14.0 ±3.7 16.5 ± 3.1 13.5 ± 2 . 9 t 0.029
4th 4.6 ± 1.9 64 ± 3.3 6.2 ±2.6 0.108
4th 4.7 ± 1.4 54 ±2.1 4.7 ± 1.7 0405
Hip flexion angle
Hip flexion angle
1st 11.9 ±3.9 8.4 ± 4.7 12.7 ± 4 . 6 t 0.022
1st 7.2 ± 2.2 7.0 ± 3.7 9.8±2.1*t 0.016
2nd 22.7 ± 7.2 16.5 ± 7.3* 23.0 ± 5.6t 0.014
2nd 20.1 ± 3.7 16.0 ± 5.6* 23.3 ± 3 . 4 t 0.000
3rd 14.9 ± 3.9 14.1 ± 3.9 16.7 ±2.9 0.142
3rd 19.6 ±3.6 14.4 ± 5.0* 20.1 ± 4.4t 0.001
4th 5.0 ± 1.8 4.47 ± 2 4 4.96 ± 1.7 0.732
4th 9.5 ± 1.9 6.7 ± 3 . 1 * 7.8 ± 4.0 0.038 P values in the ANOVA.
P vaiuesin the ANOVA. 'Significant difference compared with the controi group in the post hoc test.
"Significant difference compared with the control group in the post hoc test. fSignificant difference compared with the LFRS LBP subgroup in the post
hoc test.
fSignificant difference compared with the LFRS LBP subgroup in the post
hoc test. LERS indicates lumbar extension with rotation syndrome; LFRS, lumbar
flexion with rotation syndrome; SD, standard deviation; ANOVA, analysis of
SD indicates standard deviation; ANOVA, analysis of variance; LBP iow variance; LBP, low back pain.
back pain.

then follows. In the LERS LBP subgroup, the lumbar spine
showed a tendency for more movement than the hip in all
movement periods (Eigure 2B). The lumbopelvic rhythm dur-
ing the bending and returning periods in the LERS LBP sub-
group showed hip dominance (Eigure 2C).
In the control group, during the early and middle stages of
the bending period, the magnitude of the lumbar spine move-
ment was greater than that of the hip (first quartile) and then
was similar to that of the hip (second quartile), whereas the
relative contribution of the hip was greater than that of the
lumbar spine during the final stage (third and fourth quar-
tiles) of the bending period (Table 2). The results during the
returning period indicated that hip movement was dominant
in the early stage (first and second quartiles), but in the later
stages (third and fourth quartiles), the lumbar spine and hip
movements were performed smoothly, and the patterns were
similar (Table 3). In the LERS LBP subgroup, the mean angle
of the lumbar spine was greater than that of the control group
throughout the bending period, but the differences were not
statistically significant (P > 0.05; Table 2). The mean angle of
the hip was significantly less in the second to fourth quartiles,
compared with the control group (P < 0.05). In the returning
period, the hip angle of the LERS LBP subgroup was signifi-
cantly less in the second quartile, compared with the control
group (P < 0.05; Table 3). In the LERS LBP subgroup, the
lumbar angle in the third quartile in the bending period was
significantly less than that of the control group (? < 0.05;
Table 2), and the hip angle was significantly greater than that
1264 www.spinejournal.com
of the LERS LBP group in the first to third quartiles (? <
0.05). In the returning period, the lumbar angle in the second
quartile was significantly less than that of the control and the
LERS LBP subgroup (P < 0.05), and the hip angles in the first
and second quartile were significantly greater than those of
the LERS LBP subgroup (P < 0.05; Table 3).
The lumbar/hip movement ratios, which represent the rela-
tive contribution of the lumbar spine and hip are shown in
Table 4. Eor the control group, the lumbar/hip movement
ratio was 1 or greater in the first and second quartiles and
was less than 1 in the third and fourth quartiles during the
bending period. During the returning period, the lumbar/hip
ratio was less than 1 during the first quartile and was then
maintained at about 1 in the second to fourth quartile. Eor the
LERS LBP subgroup, the lumbar/hip movement ratio was 1
or greater in all quartiles in the bending and returning period,
and the ratios were significantly higher than those of the con-
trol group at every time interval except third quartile (P <
0.05). The LERS LBP subgroup exhibited a pattern of hip
dominance during all of the bending and returning periods.
The lumbar/hip movement ratios were less than 1 at almost
every quartile in bending and returning periods. Additionally,
the ratios were significantly lower than those of the LERS LBP
subgroup at the first, second, and third quartiles during the
bending and returning periods.
The maximal lumbar flexion angle was significantly less
and the maximal hip flexion angle was significantly greater
than that of the LERS LBP group (P < 0.05; Table 5).
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 BlOMECHANICS Lumbopelvic Rhythm and Flexion-Relaxation Response • Kim et al

TABl iK^Hios (Mean ± bU) ot tumbar to Hip TABLE 5. xiníal Ailgular Displacements
I ^ R x i o n Movement (Lumbar Angle/Hip .ean ± SD in Degrees) During the
w Angle) at Each Quartile of the Trunk F • • n i l , « "j.^|JJ,1] IB^IIII •^tUil
1 Flexion and Return Task r Control LFRS* LFRSt P
Quartile Control LFRS* LERSt p Lumbar 48.5 ± 6.9 55.4 ± 8.8* 47.8 ± 7.2§ 0.013
Bending period flexion
angle
1st 1.4 ± 0.4 2.0 ± 0.9t 1.0 ± 0.2§ 0.000
Hip flexion 56.6 ± 10.4 45.6 ± 15.4* 61.1 ± 9.8§ 0.003
2nd 1.0 ±0.2 1.5 ± 0.4* 0.8 ± 0.2§ 0.000 angle
P values in the ANOVA.
3rd 0.7 ± 0.2 1.3 ±0.5+ 0.7 ± 0.2§ 0.000
'Lumbar flexion with rotation syndrome,
4th 0.5 ± 0.2 1.0 ±0.7* 0.8 ± 0.6 0.018
f Lumbar extension with rotation syndrome.
Returning period
^Significant difference compared with the control group in the post hoc test.
1st 0.6 ± 0.4 1.2 ± 0.9* 0.5 ± 0.2§ 0.002
§Significant difference compared with the LFRS LBP subgroup in the post
2nd 1.0 ±0.5 1.5 ± 0.7* 0.8 ± 0.3§ 0.002 hoc test.

SD indicates standard deviation; ANOVA, analysis of variance; LBP, low

3rd 1.2 ± 0.2 1.4 ±0.3 1.0±0.3§
4th 1.0 ± 0.4 1.6 ±0.7* 1.3 ±0.5
P values in the ANOVA.
*Lumbar fiexion with rotation syndrome,
f Lumbar extension with rotation syndrome.
^Significant difference compared with the control group in the post hoc test.
^Significant difference compared with the LFRS LBP subgroup in the post
hoc test.
SD indicates standard deviation; ANOVA, analysis of variance; LBP, low
back pain.
The FR ratio of the ES muscle was significantly greater in
the LFRS and LERS LBP subgroups than in the control group
(P < 0.05; Tahle 6).
DISCUSSION
The results showed that the lumbopelvic rhythm in healthy
subjects was similar to that previously reported^-'*-'^'^'*; how-
ever, the lumbopelvic rhythm in the LBP groups was consid-
erably different from that reported in previous studies. The
homogeneity of the LBP subjects in this study may explain the
differing results between this and previous studies."'^
In this study, the LFRS LBP subgroup showed a significant
decrease in hip flexion with excessive lumbar flexion during
trunk flexion, compared with the control group. In the LERS
LBP subjects, the maximal lumbar flexion was lower and the
maximal hip flexion was greater than in the LFRS LBP sub-
jects. These results show that in the LFRS LBP subgroup, the
lumbar spine was flexible and the hip was relatively restricted.
In contrast, in the LERS LBP subgroup, the lumbar spine was
restricted and the hip was more flexible. Full flexion of the
trunk allows pelvic anterior rotation, combined with lumbar
flexion. The limited hip flexion in the LFRS LBP subgroup
is considered to result from shortness of hip extensors, such
as the hamstring muscle.^^ Shortening of hip extensors can
induce posterior pelvic rotation and reduce the anterior tilting
of the pelvis."* Thus, the decreased hip flexion in this group
Spine
0.003 back pain.
0.011
was likely the result of stiffness in the posterior pelvic region,
caused by shortened hip extensors. As we know from the clas-
sification tests for each LBP subgroup, the LFRS LBP subgroup
was susceptible to lumbar flexion; thus, in this group, exces-
sive lumbar flexion would likely be present during trunk flex-
ion. Also, lumbar flexion would be increased by movements
compensating for the limited hip flexion. These changes may
cause overstretching in posterior connective tissue in the lum-
bar spine and increased stress on the discs."* The lumbar flex-
ion limitation in the LERS LBP subgroup can be explained
by tightness in the lumbar extensor muscles, such as the ES
muscle. Increased lumbar extensor muscle tightness produces
anterior pelvic rotation and may induce excessive lordosis in
the lumbar spine. Thus, the LERS LBP subgroup felt pain dur-
ing lumbar extension and showed symptoms associated with
excessive lordosis in the lumbar spine.^^ Increased hip flex-
ion, combined with decreased lumbar flexion, was observed
in the LERS LBP subgroup. Hip flexion would be increased
by movements compensating for the limited lumbar flexion.^
Furthermore, the FR ratio of the ES muscle was higher for
the 2 LBP subgroups than for the control group. To a large
extent, the movement and alignment patterns that occur
during motion are produced by active muscles and passive
ligaments.^"'* According to the ligament-muscular reflex, in
normal condition, stretching of the supraspinous or inter-
spinous ligaments stimulates the mechanoreceptors that, in
turn, cause the paraspinal muscles to contract." When the
ligaments are appropriately stretched in the full flexion or the
hanging position, the stretch-inhibition reflex occurs. Conse-
quently, the paraspinal muscles relax, that is, the FR response
becomes apparent. Therefore, passive structures rather than
the paraspinal muscles provide spinal stability. However,
changes in the flexibility of the spine exert a major influence
on the neuromuscular stabilizing system."*" In the higher flex-
ible condition of lumbar spine in the LFRS LBP subgroup,
the passive elements undergo lengthening, and the reduced
www.spinejournal.com 1265
 BlOMECHANICS
TABLE 6. 1 lon-Reiaxation Ratios (Mean ± SD
igKnts)^ MAe^ ES.^^MjusQl^,ä^ittai
Control LFRS* LERSt
ES 8.9 ± 2 . 3 20.8 ± 13.2* 24.5 ± 14.4*
P values in the ANOVA.
*Lumbar flexion with rotation syndrome,
f Lumbar extension with rotation syndrome.
Significant difference compared with the control group in the post hoc test.
SD indicates standard deviation; ANOVA, analysis of variance; ES, erector
spinae.
tension is insufficient to activate the stretch-inhibition
reflex.''' Therefore the paraspinal muscles are not able to
relax, which creates greater reliance on the active muscles
during trunk flexion.''^ In contrast, in the lower flexible con-
dition of lumbar spine in the LERS LBP subgroup, the liga-
ment-muscular reflex is maintained and the stretch-inhibition
reflex does not occur because the ligaments of the lumbar
spine are not appropriately stretched.^"^ Therefore, increased
sensitivity of the ligament mechanoreceptors would result
in increased muscle activity as a result of heightened stretch
sensitivity in the muscle spindle and interference with the
stretch-inhibition reflex, caused by the continuous activity of
the spindle afférents.'^
The traditional approach in LBP of applying simplistic
single-dimensional analyses has failed to make marked dif-
ferences in patients with heterogeneous LBP. The reason for
this failure may relate to the lack of a truly patient-centered
approach, as well as the failure to evaluate other dimen-
sions, such as neurophysiological factors and maladaptive
lifestyle and movement behaviors.''^'*'' Thus, LBP should be
subgrouped, in detail, based on neurophysiological character-
istics, pain behaviors, and movement behaviors, for multidi-
mensional approaches to LBP.'''' To date, many studies have
reported that the ER response of the ES muscle is an indica-
tor of LBP. In this study, the ER response of the ES muscle
disappeared in both LBP subtypes, although the LERS and
LERS LBP subtypes showed differing lumbopelvic rhythms.
We found that the ER response was indistinguishable in the
LBP subtypes with altered lumbopelvic rhythms. This result
suggests that need for new categories to differentiate, in detail,
LBP subtypes, based on movement behaviors, such as the
lumbopelvic rhythm during trunk flexion. We suggest that cli-
nicians attempt to recover normal lumbopelvic movement in
patients in the LERS and LERS subgroups. These character-
istics of the LBP subtypes may provide a more intensive and
person-targeted framework for the treatment of LBP.
CONCLUSION
The LERS LBP subgroup showed lumbopelvic rhythms with
excessive lumbar flexion and limited hip flexion, and a ER
response of the ES muscle was observed. The LERS LBP
subgroup showed lumbopelvic rhythms with limited lumbar
flexion and excessive hip flexion, and a ER response of the ES
1266 www.spinejournal.com
Lumbopelvic Rhythm and Flexion-Relaxation Response • Kim et al
muscle was observed. This study provides information that
will aid in the clinical assessment of movement patterns and the
measurement of related factors. Also, these results may help
P clinicians classify patients into LBP subtypes, thereby improv-
ing the selection of appropriate treatment interventions.
0.005
Key Points
• The lumbopelvic rhythms and FR response ofthe
ES muscle during the trunk flexion and return task
were evaluated in healthy subjects and in 2 different
subgroups of patients with LBP.
• The "LFRS" LBP subgroup showed lumbopelvic ;
rhythms with greater lumbar flexion and less hip
flexion, and a higher FR ratio forthe ES muscle.
• The "LERS" LBP subgroup showed lumbopelvic
rhythms with less lumbarflexion and greater hip
flexion, and a higher FR ratio forthe ES muscle.
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