A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction

European Spine Journal volume 15, pages668–676(2006)Cite this article

Abstract

Clinical reports and research studies have documented the behavior of chronic low back and neck pain patients. A few hypotheses have attempted to explain these varied clinical and research findings. A new hypothesis, based upon the concept that subfailure injuries of ligaments (spinal ligaments, disc annulus and facet capsules) may cause chronic back pain due to muscle control dysfunction, is presented. The hypothesis has the following sequential steps. Single trauma or cumulative microtrauma causes subfailure injuries of the ligaments and embedded mechanoreceptors. The injured mechanoreceptors generate corrupted transducer signals, which lead to corrupted muscle response pattern produced by the neuromuscular control unit. Muscle coordination and individual muscle force characteristics, i.e. onset, magnitude, and shut-off, are disrupted. This results in abnormal stresses and strains in the ligaments, mechanoreceptors and muscles, and excessive loading of the facet joints. Due to inherently poor healing of spinal ligaments, accelerated degeneration of disc and facet joints may occur. The abnormal conditions may persist, and, over time, may lead to chronic back pain via inflammation of neural tissues. The hypothesis explains many of the clinical observations and research findings about the back pain patients. The hypothesis may help in a better understanding of chronic low back and neck pain patients, and in improved clinical management.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

US$ 39.95

Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3

References

  1. 1.

    Andersson GB (1997) The epidemilogy of spinal disorders, 2nd edn. Lippincott-Raven, Philadelphia

    Google Scholar 

  2. 2.

    Antonaci F, Bulgheroni M, Ghirmai S et al (2002) 3D kinematic analysis and clinical evaluation of neck movements in patients with whiplash injury. Cephalalgia 22:533–542

    Article  PubMed  Google Scholar 

  3. 3.

    Bigos SJ, Spengler DM, Martin NA et al (1986) Back injuries in industry: a retrospective study. III. Employee-related factors. Spine 11:252–256

    PubMed  Google Scholar 

  4. 4.

    Bonelli A, Donati P, Maltoni G et al (2000) Neck motion evaluation after whiplash: a radiographic and kinematic protocol. Ital J Anat Embryol 105:51–62

    Google Scholar 

  5. 5.

    Borenstein DG, Korn S (2003) Efficacy of a low-dose regimen of cyclobenzaprine hydrochloride in acute skeletal muscle spasm: results of two placebo-controlled trials. Clin Ther 25:1056–1073

    Article  PubMed  Google Scholar 

  6. 6.

    Brown MF, Hukkanen MV, McCarthy ID et al (1997) Sensory and sympathetic innervation of the vertebral endplate in patients with degenerative disc disease. J Bone Joint Surg Br 79:147–153

    Article  PubMed  Google Scholar 

  7. 7.

    Brumagne S, Cordo P, Lysens R et al (2000) The role of paraspinal muscle spindles in lumbosacral position sense in individuals with and without low back pain. Spine 25:989–994

    Article  PubMed  Google Scholar 

  8. 8.

    Burke JG, Watson RW, McCormack D et al (2002) Intervertebral discs which cause low back pain secrete high levels of proinflammatory mediators. J Bone Joint Surg Br 84:196–201

    Article  PubMed  Google Scholar 

  9. 9.

    Butler D, Trafimow JH, Andersson GB et al (1990) Discs degenerate before facets. Spine 15:111–113

    PubMed  Google Scholar 

  10. 10.

    Byl NN, Sinnott PL (1991) Variations in balance and body sway in middle-aged adults: subjects with healthy backs compared with subjects with low-back dysfunction. Spine 16:325–330

    PubMed  Google Scholar 

  11. 11.

    Cavanaugh JM, Ozaktay AC, Yamashita T et al (1997) Mechanisms of low back pain: a neurophysiologic and neuroanatomic study. Clin Orthop 166–180

    Google Scholar 

  12. 12.

    Cornefjord M, Olmarker K, Otani K et al (2002) Nucleus pulposus-induced nerve root injury: effects of diclofenac and ketoprofen. Eur Spine J 11:57–61

    Article  PubMed  Google Scholar 

  13. 13.

    Farfan HF, Sullivan JD (1967) The relation of facet orientation to intervertebral disc failure. Can J Surg 10:179–185

    PubMed  Google Scholar 

  14. 14.

    Feipel V, Rondelet B, LePallec JP et al (1999) The use of disharmonic motion curves in problems of the cervical spine. Int Orthop 23:205–209

    Article  PubMed  Google Scholar 

  15. 15.

    Freemont AJ, Peacock TE, Goupille P et al (1997) Nerve ingrowth into diseased intervertebral disc in chronic back pain. Lancet 350:178–181

    Article  PubMed  Google Scholar 

  16. 16.

    Freemont AJ, Watkins A, Le Maitre C et al (2002) Nerve growth factor expression and innervation of the painful intervertebral disc. J Pathol 197:286–292

    Article  PubMed  Google Scholar 

  17. 17.

    Frymoyer JW, Cats-Baril WL (1991) An overview of the incidences and costs of low back pain. Orthop Clin North Am 22:263–271

    PubMed  Google Scholar 

  18. 18.

    Fujiwara A, Tamai K, An HS et al (2000) The relationship between disc degeneration, facet joint osteoarthritis, and stability of the degenerative lumbar spine. J Spinal Disord 13:444–450

    Article  PubMed  Google Scholar 

  19. 19.

    Heikkila H, Astrom PG (1996) Cervicocephalic kinesthetic sensibility in patients with whiplash injury. Scand J Rehabil Med 28:133–138

    PubMed  Google Scholar 

  20. 20.

    Hodges PW, Richardson CA (1996) Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis. Spine 21:2640–2650

    Article  PubMed  Google Scholar 

  21. 21.

    Indahl A, Kaigle AM, Reikeras O et al (1997) Interaction between the porcine lumbar intervertebral disc, zygapophysial joints, and paraspinal muscles. Spine 22:2834–2840

    Article  PubMed  Google Scholar 

  22. 22.

    Jull GA, Richardson CA (2000) Motor control problems in patients with spinal pain: a new direction for therapeutic exercise. J Manipulative Physiol Ther 23:115–117

    Article  PubMed  Google Scholar 

  23. 23.

    Kankaanpaa M, Taimela S, Airaksinen O et al (1999) The efficacy of active rehabilitation in chronic low back pain. Effect on pain intensity, self-experienced disability, and lumbar fatigability. Spine 24:1034–1042

    Article  PubMed  Google Scholar 

  24. 24.

    Kelsey JL, White AA III (1980) Epidemiology and impact of low-back pain. Spine 5:133–142

    PubMed  Google Scholar 

  25. 25.

    Kirkaldy-Willis WH, Wedge JH, Yong-Hing K et al (1978) Pathology and pathogenesis of lumbar spondylosis and stenosis. Spine 3:319–328

    PubMed  Google Scholar 

  26. 26.

    Kojima Y, Maeda T, Arai R et al (1990) Nerve supply to the posterior longitudinal ligament and the intervertebral disc of the rat vertebral column as studied by acetylcholinesterase histochemistry. I. Distribution in the lumbar region. J Anat 169:237–246

    PubMed  Google Scholar 

  27. 27.

    Kristjansson E, Leivseth G, Brinckmann P et al (2003) Increased sagittal plane segmental motion in the lower cervical spine in women with chronic whiplash-associated disorders, Grades I-II: a case-control study using a new measurement protocol. Spine 28:2215–2221

    Article  PubMed  Google Scholar 

  28. 28.

    Lariviere C, Gagnon D, Loisel P (2000) The comparison of trunk muscles EMG activation between subjects with and without chronic low back pain during flexion-extension and lateral bending tasks. J Electromyogr Kinesiol 10:79–91

    Article  PubMed  Google Scholar 

  29. 29.

    Lipson SJ, Fox DA, Sosman JL (1985) Symptomatic intravertebral disc herniation (Schmorl’s node) in the cervical spine. Ann Rheum Dis 44:857–859

    PubMed  Google Scholar 

  30. 30.

    Long DM, BenDebba M, Torgerson WS et al (1996) Persistent back pain and sciatica in the United States: patient characteristics. J Spinal Disord 9:40–58

    PubMed  Google Scholar 

  31. 31.

    Loudon JK, Ruhl M, Field E (1997) Ability to reproduce head position after whiplash injury. Spine 22:865–868

    Article  PubMed  Google Scholar 

  32. 32.

    Lund JP, Donga R, Widmer CG et al (1991) The pain-adaptation model: a discussion of the relationship between chronic musculoskeletal pain and motor activity. Can J Physiol Pharmacol 69:683–694

    PubMed  Google Scholar 

  33. 33.

    Luoto S, Aalto H, Taimela S et al (1998) One-footed and externally disturbed two-footed postural control in patients with chronic low back pain and healthy control subjects. A controlled study with follow-up (discussion 9–90). Spine 23:2081–2089

    Article  PubMed  Google Scholar 

  34. 34.

    Madeleine P, Prietzel H, Svarrer H et al (2004) Quantitative posturography in altered sensory conditions: a way to assess balance instability in patients with chronic whiplash injury. Arch Phys Med Rehabil 85:432–438

    Article  PubMed  Google Scholar 

  35. 35.

    Magnusson ML, Aleksiev A, Wilder DG et al (1996) European Spine Society–the AcroMed Prize for Spinal Research 1995. Unexpected load and asymmetric posture as etiologic factors in low back pain. Eur Spine J 5:23–35

    Article  PubMed  Google Scholar 

  36. 36.

    McLain RF (1994) Mechanoreceptor endings in human cervical facet joints. Spine 19:495–501

    PubMed  Google Scholar 

  37. 37.

    Newcomer KL, Jacobson TD, Gabriel DA et al (2002) Muscle activation patterns in subjects with and without low back pain. Arch Phys Med Rehabil 83:816–821

    Article  PubMed  Google Scholar 

  38. 38.

    Newcomer KL, Laskowski ER, Yu B et al (2000) Differences in repositioning error among patients with low back pain compared with control subjects. Spine 25:2488–2493

    Article  PubMed  Google Scholar 

  39. 39.

    Norris SH, Watt I (1983) The prognosis of neck injuries resulting from rear-end vehicle collisions. J Bone Joint Surg Br 65:608–611

    PubMed  Google Scholar 

  40. 40.

    Osti OL, Vernon-Roberts B, Fraser RD (1990) 1990 Volvo Award in experimental studies. Anulus tears and intervertebral disc degeneration. An experimental study using an animal model. Spine 15:762–767

    PubMed  Google Scholar 

  41. 41.

    Osti OL, Vernon-Roberts B, Moore R et al (1992) Annular tears and disc degeneration in the lumbar spine. A post-mortem study of 135 discs. J Bone Joint Surg Br 74:678–682

    PubMed  Google Scholar 

  42. 42.

    O’Sullivan PB, Burnett A, Floyd AN et al (2003) Lumbar repositioning deficit in a specific low back pain population. Spine 28:1074–1079

    Article  PubMed  Google Scholar 

  43. 43.

    Oxland TR, Crisco JJ III, Panjabi MM et al (1992) The effect of injury on rotational coupling at the lumbosacral joint. A biomechanical investigation. Spine 17:74–80

    PubMed  Google Scholar 

  44. 44.

    Palmgren T, Gronblad M, Virri J et al (1996) Immunohistochemical demonstration of sensory and autonomic nerve terminals in herniated lumbar disc tissue. Spine 21:1301–1306

    Article  PubMed  Google Scholar 

  45. 45.

    Panjabi M (1979) Validation of mathematical models. J Biomech 12:238

    Article  PubMed  Google Scholar 

  46. 46.

    Panjabi MM (1992) The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement (discussion 97). J Spinal Disord 5:383–389

    PubMed  Google Scholar 

  47. 47.

    Panjabi MM (1992) The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis (discussion 7). J Spinal Disord 5:390–396

    PubMed  Google Scholar 

  48. 48.

    Panjabi MM, Yoldas E, Oxland TR et al (1996) Subfailure injury of the rabbit anterior cruciate ligament. J Orthop Res 14:216–222

    Article  PubMed  Google Scholar 

  49. 49.

    Patijn J, Wilmink J, ter Linden FH et al (2001) CT study of craniovertebral rotation in whiplash injury. Eur Spine J 10:38–43

    Article  PubMed  Google Scholar 

  50. 50.

    Patwardhan AG, Havey RM, Ghanayem AJ et al (2000) Load-carrying capacity of the human cervical spine in compression is increased under a follower load. Spine 25:1548–1554

    Article  PubMed  Google Scholar 

  51. 51.

    Puglisi F, Ridi R, Cecchi F et al (2004) Segmental vertebral motion in the assessment of neck range of motion in whiplash patients. Int J Legal Med 118:235–239

    Article  PubMed  Google Scholar 

  52. 52.

    Radebold A, Cholewicki J, Panjabi MM et al (2000) Muscle response pattern to sudden trunk loading in healthy individuals and in patients with chronic low back pain. Spine 25:947–954

    Article  PubMed  Google Scholar 

  53. 53.

    Radebold A, Cholewicki J, Polzhofer GK et al (2001) Impaired postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain. Spine 26:724–730

    Article  PubMed  Google Scholar 

  54. 54.

    Roland MO (1986) A critical review of the evidence for a pain-spasm-pain cycle in spinal disorders. Clin Biomech (Bristol, Avon) 1:102–109

    Google Scholar 

  55. 55.

    Ronnen HR, de Korte PJ, Brink PR et al (1996) Acute whiplash injury: is there a role for MR imaging?–a prospective study of 100 patients. Radiology 201:93–96

    PubMed  Google Scholar 

  56. 56.

    Rosenfeld M, Seferiadis A, Carlsson J et al (2003) Active intervention in patients with whiplash-associated disorders improves long-term prognosis: a randomized controlled clinical trial. Spine 28:2491–2498

    Article  PubMed  Google Scholar 

  57. 57.

    Salminen JJ, Erkintalo MO, Pentti J et al (1999) Recurrent low back pain and early disc degeneration in the young. Spine 24:1316–1321

    Article  PubMed  Google Scholar 

  58. 58.

    Sekine M, Yamashita T, Takebayashi T et al (2001) Mechanosensitive afferent units in the lumbar posterior longitudinal ligament. Spine 26:1516–1521

    Article  PubMed  Google Scholar 

  59. 59.

    Solomonow M, Zhou B, Baratta RV et al (2002) Neuromuscular disorders associated with static lumbar flexion: a feline model. J Electromyogr Kinesiol 12:81–90

    Article  PubMed  Google Scholar 

  60. 60.

    Solomonow M, Zhou BH, Baratta RV et al (2003) Biomechanics and electromyography of a cumulative lumbar disorder: response to static flexion. Clin Biomech (Bristol, Avon) 18:890–898

    Google Scholar 

  61. 61.

    Solomonow M, Zhou BH, Baratta RV et al (1999) Biomechanics of increased exposure to lumbar injury caused by cyclic loading: Part 1. Loss of reflexive muscular stabilization. Spine 24:2426–2434

    Article  PubMed  Google Scholar 

  62. 62.

    Solomonow M, Zhou BH, Harris M et al (1998) The ligamento-muscular stabilizing system of the spine. Spine 23:2552–2562

    Article  PubMed  Google Scholar 

  63. 63.

    Spitzer WO, Skovron ML, Salmi LR et al (1995) Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining “whiplash” and its management. Spine 20:1S–73S

    PubMed  Google Scholar 

  64. 64.

    Taimela S, Diederich C, Hubsch M et al (2000) The role of physical exercise and inactivity in pain recurrence and absenteeism from work after active outpatient rehabilitation for recurrent or chronic low back pain: a follow-up study. Spine 25:1809–1816

    Article  PubMed  Google Scholar 

  65. 65.

    Taimela S, Osterman K, Alaranta H et al (1993) Long psychomotor reaction time in patients with chronic low-back pain: preliminary report. Arch Phys Med Rehabil 74:1161–1164

    PubMed  Google Scholar 

  66. 66.

    Taimela S, Takala EP, Asklof T et al (2000) Active treatment of chronic neck pain: a prospective randomized intervention. Spine 25:1021–1027

    PubMed  Google Scholar 

  67. 67.

    Tarsy D (1998) Comparison of acute- and delayed-onset posttraumatic cervical dystonia. Mov Disord 13:481–485

    Article  PubMed  Google Scholar 

  68. 68.

    Tawackoli W, Marco R, Liebschner MA (2004) The effect of compressive axial preload on the flexibility of the thoracolumbar spine. Spine 29:988–993

    Article  PubMed  Google Scholar 

  69. 69.

    van Dieen JH, Selen LP, Cholewicki J (2003) Trunk muscle activation in low-back pain patients, an analysis of the literature. J Electromyogr Kinesiol 13:333–351

    Article  PubMed  Google Scholar 

  70. 70.

    Vezina MJ, Hubley-Kozey CL (2000) Muscle activation in therapeutic exercises to improve trunk stability. Arch Phys Med Rehabil 81:1370–1379

    Article  PubMed  Google Scholar 

  71. 71.

    Wasiak R, Pransky G, Verma S et al (2003) Recurrence of low back pain: definition-sensitivity analysis using administrative data. Spine 28:2283–2291

    Article  PubMed  Google Scholar 

  72. 72.

    White AA III, Gordon SL (1982) Symposium on idiopathic low back pained. C.V. Mosby, St. Louis

    Google Scholar 

  73. 73.

    White AA III, Panjabi MM (1990) Clinical Biomechanics of the Spine, 2nd edn. Lippincott, Philadelphia

    Google Scholar 

  74. 74.

    Wilke HJ, Wolf S, Claes LE et al (1995) Stability increase of the lumbar spine with different muscle groups. A biomechanical in vitro study. Spine 20:192–198

    PubMed  Google Scholar 

  75. 75.

    Williams M, Solomonow M, Zhou BH et al (2000) Multifidus spasms elicited by prolonged lumbar flexion. Spine 25:2916–2924

    Article  PubMed  Google Scholar 

  76. 76.

    Yamashita T, Cavanaugh JM, el-Bohy AA et al (1990) Mechanosensitive afferent units in the lumbar facet joint. J Bone Joint Surg Am 72:865–870

    PubMed  Google Scholar 

  77. 77.

    Yang KH, King AI (1984) Mechanism of facet load transmission as a hypothesis for low-back pain. Spine 9:557–565

    PubMed  Google Scholar 

Download references

Acknowledgements

I would like to express my sincere thanks to Elena Gimenez, Paul Ivancic, Kim Reid, and James Yue for their valuable advice, and assistance. I also want to thank the anonymous reviewers for their thoughtful suggestions to improve the manuscript. Further, I would like to acknowledge the grant support over many years from the National Institutes of Health.

Author information

Affiliations

  1. Biomechanics Research Laboratory, Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Box 208071, CT, 06520-8071, USA

    Manohar M. Panjabi

Authors
  1. Manohar M. Panjabi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Manohar M. Panjabi.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Panjabi, M.M. A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction. Eur Spine J 15, 668–676 (2006). https://doi.org/10.1007/s00586-005-0925-3

Download citation

Keywords

  • Low back pain
  • Neck pain
  • Whiplash
  • Biomechanics
  • Hypothesis