Joint Bone Spine 74 (2007) 9e13

http://france.elsevier.com/direct/BONSOI/

Review

Spinal muscle evaluation in healthy individuals and low-back-pain

patients: a literature review
Christophe Demoulin*, Jean-Michel Crielaard, Marc Vanderthommen
Physical Therapy and Rehabilitation Department, ISEPK B21, Lie`ge University, Allee des Sports 4, B-4000 Lie`ge-Sart Tilman, Belgium
Received 20 July 2005; accepted 6 February 2006
Available online 13 November 2006

Abstract
This article reviews available techniques for spinal muscle investigation, as well as data on spinal muscles in healthy individuals and in
patients with low back pain. In patients with chronic low back pain, medical imaging studies show paraspinal muscle wasting with reductions
in cross-sectional surface area and fiber density. In healthy individuals, the paraspinal muscles contain a high proportion of slow-twitch fibers
(Type I), reflecting their role in maintaining posture. The proportion of Type I fibers is higher in females, leading to better adaptation to aerobic
exertion compared to males. Abnormalities seen in paraspinal muscles from patients with chronic low back pain include marked Type II fiber
atrophy, conversion of Type I to Type II fibers, and an increased number of nonspecific abnormalities. Limited data are available from
magnetic resonance spectroscopy used to investigate muscle metabolism and from near infrared spectroscopy used to measure oxygen uptake
by the paraspinal muscles. Surface electromyography in patients with chronic low back pain shows increased paraspinal muscle fatigability,
often with abolition of the flexion-relaxation phenomenon.
2006 Elsevier Masson SAS. All rights reserved.
Keywords: Paraspinal muscles; Muscle biopsy; Spectroscopy; Electromyography

1. Introduction

2. Methods

Active exercise therapy is the only effective means of limiting physical deconditioning in patients with chronic low back
pain [1]. Physical deconditioning manifests as decreased
strength and endurance, most notably of the trunk extensor
muscles [1,2]. The paraspinal muscles play an important role
as stabilizers and therefore have been a focus of active research. This article describes methods for investigating the
paraspinal muscles and reviews data from healthy individuals
and from patients with low back pain. We excluded data limited to muscle performance (e.g., strength and endurance) in
patients with chronic low back pain, as they are strongly influenced by factors such as pain, anticipated pain, and
motivation.

We searched the Medline database using the keywords trunk

extensors, erector spinae, paraspinal muscle, muscle fatigue, back pain, muscle biopsy, fiber types, MRI,
magnetic resonance imaging, computerized tomography,
CT scan, cross-sectional area, density, real-time ultrasound, magnetic resonance spectroscopy, NIRS, tissue
oxygenation, electromyography, and flexion-relaxation.

* Corresponding author. Tel.: 32 4 366 3947; fax: 32 4 366 2901.

E-mail address: chris_demoulin@hotmail.com (C. Demoulin).

3. Results
3.1. Medical imaging studies
Medical imaging techniques provide noninvasive and reproducible [3,4] information on muscle cross-sectional surface
area (CSA) and/or density of a specific muscle or group of
muscles. In contrast to computed tomography (CT), magnetic
resonance imaging (MRI) does not involve X-ray exposure [5].

1297-319X/$ - see front matter 2006 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.jbspin.2006.02.013

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C. Demoulin et al. / Joint Bone Spine 74 (2007) 9e13

However, MRI cannot be performed in patients with implanted

metallic objects. Ultrasonography is more widely available
than MRI and provides a fairly reproducible evaluation of
muscle degeneration [6]. However, ultrasonography cannot
be used to evaluate large-diameter muscles, to accurately determine the vertebral level, or to obtain accurate measurements
of muscle density [6].
In healthy individuals, MRI and CT may show disk degeneration or nerve root compression. However, these findings neither predict the risk of low back pain nor correlate
with clinical symptoms [5]. Paraspinal muscles as evaluated
using medical imaging studies vary widely across individuals
[7] and between men and women [7]. CSA is smaller in
women than men [8] and increases in the cephalad to caudad
direction, with a large increase occurring in the multifidus
muscle [4]. Hides et al. [6] found no difference between
the right and left sides. CSA decreased with advancing age
in one study [9] but was independent from age in two other
studies [8,10].
In patients with chronic low back pain, medical imaging
studies of the paraspinal muscles consistently show a decrease
in CSA [4,11], which may reach 10% compared to healthy individuals [1], and a decrease in muscle density [1], indicating
muscle wasting. Physical deconditioning and decreased activity may contribute to muscle wasting [1], although CSA is not
correlated with symptom duration [9]. Whether pain and muscle wasting are causally related remains unclear [11]. Neither
is there firm evidence that CSA correlates with muscle performance. Positive correlations between imaging study findings
and muscle performance were noted in some studies [8,12]
but not in others [1,13]. These discrepancies may be ascribable
to lack of accuracy in CSA measurement [8,12] and/or to lack
of specificity of muscle performance assessments [14]. Furthermore, muscle density was not correlated to maximum
strength [1].
Studies investigating the effects of reconditioning programs on paraspinal muscle CSA in patients with chronic
low back pain have produced conflicting results. In two studies, no changes were documented after an active rehabilitation program known to improve pain and function [12,13].
In contrast, multifidus CSA increased significantly after several weeks of stabilization and dynamic-static resistance
training [15]. Similarly, a 15-week program for patients
with subacute low back pain induced nonsignificant changes
in CSA (increase of about 2e3%) and in muscle fat [16].
These inconsistent and modest effects on CSA may indicate
that current reconditioning programs are neither sufficiently
intense nor sufficiently long. Heavy resistance training for
at least 8 weeks is needed to achieve muscle hypertrophy
[17]. The strength increases achieved during the first few
weeks of rehabilitation are mainly ascribable to neurological
adjustments (e.g., better coordination and motor unit synchronization) [17]. MRI can be used to obtain functional information during muscle contraction, since T2 proton relaxation
time is highly sensitive to water content [18], which increases
after exertion [19]. Flicker et al. used MRI to compare the activity of the multifidus and longissimus/iliocostalis muscles at

rest and after Roman chair extension exercises in normal individuals, chronic low back pain patients without surgery, and
chronic low back pain patients with surgery [19]. At rest, signal intensity was lower in the surgery group, suggesting fibrosis and/or fatty infiltration compared to the other two groups.
After exertion, the signal increase due to osmotic events was
smaller in the surgery group. Flicker et al. suggested that severe muscle deconditioning in surgically treated patients
might explain their results [19].
3.2. Muscle biopsy
Muscle fiber type and size can be determined in muscle biopsy specimens. Because muscle biopsy is an invasive investigation, most studies of muscle histology relied on
specimens obtained during surgery [20] or autopsy [2,20e
22]. However, a few studies of percutaneous muscle biopsies
have been reported [7,23,24].
In healthy individuals, studies showed a large proportion
(54e73%) of slow-twitch fibers (Type I) [2,25], in keeping
with the postural role of the paraspinal muscles. The relative
area of muscle occupied by Type I fibers is larger in women
than in men [7], a fact that may explain the better performance
of women on paraspinal muscle endurance tests [14,26]. An
increase in Type I fiber proportion with advancing age has
been reported [9,20]. Differences in muscle fiber type distribution between the multifidus and the longissimus/iliocostalis
muscles and between the thoracic and the lumbar segments remain controversial [2,7,20e22]. Type I fibers in the paraspinal
muscles are larger than those in other muscle groups
[21,22,24,25].
Conflicting results have been obtained in patients with low
back pain. Predominant Type II atrophy has been reported after surgery for low back pain [27]. In contrast, Crossman et al.
found no difference between healthy individuals and low back
pain patients regarding fiber size, proportion of Type I fibers,
or relative area occupied by Type I fibers [24]. Mannion et al.
[23] reported a decrease in the proportion of Type I fibers relative to fast-twitch Type IIB and Type IIC fibers, in keeping
with the lower endurance noted in low back pain patients
[28]. Conversion of Type I to Type II fibers has been described
in association with physical deconditioning or immobility
[29]. Fiber type changes correlate with symptom duration,
supporting a role for physical deconditioning [9]. Nonspecific
muscle fiber abnormalities include core targetoid muscle fibers, small angulated muscle fibers, and moth-eaten fibers
[23,27]. Fiber type distribution was unchanged in low back
pain patients after 3 months of active rehabilitation, despite
improvements in muscle performance [12]. A 5-week intensive program followed by an 8-week home exercise program
was associated with a significant increase in multifidus Type
II fiber size in men, a finding that probably reflects the specific
nature of the exercises; the increase was not significant in
women [30]. Muscle biopsy is an invasive procedure that raises ethical problems when used for investigational purposes in
patients who do not require surgery. In addition, the substantial
variability across individuals [2,7,24] and across biopsies from

C. Demoulin et al. / Joint Bone Spine 74 (2007) 9e13

the same muscle in a given individual [31] limit the usefulness

of muscle biopsy.
3.3. Nuclear magnetic resonance spectroscopy (NMRS)
Nuclear magnetic resonance spectroscopy (NMRS) measures signals generated by selected atom nuclei (usually 1H
or 31P) in response to radiofrequency pulses. This noninvasive
and nonionizing method has been validated for investigating
skeletal muscle metabolism [32,33]. A strong external magnetic field is needed. NMRS of the 31P nucleus can detect
high-energy metabolites such as adenosine triphosphate
(ATP), creatine phosphate (PCr), and inorganic phosphate
(Pi). The surface area of the PCr and Pi peaks, which is proportional to the number of spinning nuclei, can be used to determine ratios (Pi/PCr) or tissue concentrations of specific
molecules. Changes in the concentration of phosphorylated
compounds and in intracellular pH induced by exertion and recovery can be measured using NMRS. In addition, information
on fiber composition can be obtained [34]. NMRS has been
used in many studies to investigate peripheral limb muscles
[32,33]. Whole-body magnets are required for NMRS of the
axial muscles [35]. Their limited availability, together with
the difficulty of standardizing paraspinal muscle exercises, explain why few studies of paraspinal muscle NMRS have been
published. Strobel et al. used 31P NMRS to investigate the paraspinal muscles at L3eL4 in healthy individuals and in patients with low back pain or fibromyalgia [36]. The Pi/PCr
ratio at rest was higher in the patients with chronic pain
than in the controls, suggesting that pain was associated
with incomplete muscle relaxation.
3.4. Near infrared spectroscopy (NIRS)
Near infrared spectroscopy (NIRS) is based on differences
in the absorption of near infrared light between oxygenated
and nonoxygenated hemoglobin and myoglobin. Thus, NIRS
produces noninvasive and reproducible measurements of tissue
oxygenation [37]. Because absorption is similar for hemoglobin, which reflects oxygen in the bloodstream, and myoglobin,
which reflects oxygen in the tissue, NIRS fails to differentiate
between vascular and cellular oxygenation. Wilson et al. suggested that hemoglobin might have a predominant influence on
the NIRS signal [38]. In healthy individuals, paraspinal muscle
oxygenation decreases when contraction intensity exceeds 2%
of the maximum voluntary contraction [39]. Thus, oxygen
supply is compromised during prolonged maintenance of postures that require low-level isometric contractions. Oxygen use
by the paraspinal muscles was decreased in patients with low
back pain compared to healthy individuals [40]. Possible explanations include mitochondrial injury responsible for decreased oxidative enzyme activity and a specific pattern of
muscle fiber recruitment. The decrease in oxygen use is consistent with the alteration in aerobic muscle performance associated with low back pain. These findings underscore the need
for specific rehabilitation of the paraspinal muscles [40].

11

3.5. Electromyography (EMG)

Intramuscular (needle) or surface electromyography has
been used to investigate paraspinal muscle activity and/or fatigability. Surface electromyography (SEMG) is noninvasive
but cannot be used to investigate deep muscles. In addition,
SEMG does not reliably isolate the activity of a specific muscle [41]. Nevertheless, the results of intramuscular EMG and
SEMG seem correlated to each other [42]. The absence of
standardized EMG protocols complicates comparisons. In addition, EMG results are influenced by many factors including
the type, size, and location of the electrodes; the impedance of
the source and amplifier; the location of the motor points; the
type of contraction; the temperature of the muscle and skin;
the force produced by the contraction; fiber composition and
blood flow; and fat layer thickness [43]. Whereas intra-session
reproducibility seems satisfactory [44], inter-session and interoperator reproducibility are controversial [45]. The most
widely used EMG parameters include the root mean square
(RMS), initial median frequency (IMF), median frequency
(MF), mean power frequency (MPF), as well as their rates
of decline, which reflect fatigability during prolonged exercise. These parameters are derived from raw EMG data and
usually analyzed by fast Fourier transform. Instantaneous median frequency (IMDF) is a recently described parameter that
provides reproducible assessments during dynamic tasks [46].
Roy et al. developed the Back Analysis System to standardize
assessments of back muscle dysfunction associated with
chronic low back pain [47]. This system, which has been
used by other groups [43], records SEMG signals during repeated isometric extensions at a given percentage of the maximum voluntary contraction. Therefore, maximum voluntary
contraction must be determined first [48]. In patients with
low back pain, apprehension and/or pain may lead to underestimation of the maximum voluntary contraction [49]. Fatigability can also be assessed using EMG coupled to other
dynamometers [28] or the Sorensen test [14,44], in which
the patient is asked to hold the unsupported trunk
horizontal while lying prone with the legs and buttocks strapped to the examination table and the pelvis at the edge of the
table [50].
In healthy individuals, the mean MF slope was correlated
with the holding time [14,28]. Endurance exercises coupled
with SEMG may be useful for quantifying fatigability without
requiring maximum contraction. Holding times are longer in
women, indicating lower paraspinal muscle fatigability compared to men, as confirmed by EMG studies [14,28].
Paraspinal muscle fatigability is increased in patients with
low back pain [47,51]. A likely mechanism is physical
deconditioning responsible for muscle wasting with predominant loss of Type I fibers. The relative area occupied by
Type I fibers correlates with the slope of spectral EMG
parameters [21,26]. SEMG was used to show improvements
in paraspinal muscle fatigability induced by an intensive
(40 h/week) 4-week rehabilitation program designed chiefly
to improve muscle performance in patients with chronic
low back pain [51].

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C. Demoulin et al. / Joint Bone Spine 74 (2007) 9e13

The flexion/relaxation phenomenon can be investigated using intramuscular EMG or SEMG. Normally, electrical silence
of lumbar paraspinal muscles occurs toward the end of trunk
flexion [52e55]. This relaxation occurs when tension on passive structures, such as ligaments, and/or on the thoracolumbar
fascia counterbalances the weight of the trunk [54e56]. Inhibition of paraspinal muscles induced by activation of stretch
receptors has been suggested as a possible mechanism [55].
Alternatively, deeper muscles that are difficult to record may
undergo activation [56]. Although multifactorial [55], the flexion/relaxation phenomenon can be reliably documented by
EMG and discriminates between patients with and without
low back pain [57]. Absence of the flexion/relaxation phenomenon in low back pain patients [53,57] may be ascribable to
muscle spasm [57], reduced range of motion [57], exaggerated
stretch reflexes [57], or an effort to protect damaged passive
structures [54]. Restoration of the flexion/relaxation phenomenon has been reported to occur with rehabilitation therapy
in most low back pain patients [53].
New techniques such as large-array SEMG (LASE) allow
simultaneous RMS recording of several muscle groups [58].
A specific pattern of muscle group activation that protects
the diseased site may occur in patients with low back pain
[58]. However, the validity of SEMG remains controversial
[41,59]. The considerable inter-individual variability [60]
and the absence of normative data complicate the description
of normal or abnormal profiles, thereby limiting the diagnostic
usefulness of SEMG [59]. However, SEMG is reliable for
evaluating fatigability and may serve to determine the relative
area occupied by Type I fibers [26].
4. Conclusions
Muscle biopsy, MRI, CT, NMRS, NIRS, SEMG, and intramuscular EMG can supply valuable information on the paraspinal muscles. Additional studies are needed to identify the
most reliable and relevant variables for monitoring chronic
low back pain patients in clinical practice. Many studies
showed decreased CSA and increased fatigability of the paraspinal muscles in patients with low back pain. Whether these
changes are causes or consequences of low back pain remains
unknown.
Acknowledgments
We thank Ms. Annie Depaifve for technical assistance and
Paul Rime Inc. for financial support.
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