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Quantifying the Lumbar Flexion–Relaxation Phenomenon: Theory, Normative Data, and Clinical Applications

Neblett, Randy, MA, LPC, BCIA-C*; Mayer, Tom G., MD; Gatchel, Robert J., PhD; Keeley, Janice, PT*; Proctor, Tim, PhD*; Anagnostis, Christopher, PhD*

doi: 10.1097/01.BRS.0000067085.46840.5A

Study Design. A two-part investigation was conducted: 1) a prospective study of asymptomatic subjects quantitatively comparing trunk mobility to surface electromyographic (sEMG) signals from the erector spinae during trunk flexion; and 2) a prospective repeated-measures cohort study of patients with chronic disabled work-related spinal disorder tested for the flexion–relaxation (FR) phenomenon while measured simultaneously for lumbar spine inclinometric range of motion (ROM).

Objectives. To describe a theoretical model for the potential use of FR unloaded in assessing patients with chronic low back pain patients before and after rehabilitation, and to establish a normative database (Part 1) for subsequent use in comparison to patients with chronic low back pain (Part 2). The second part of the study assessed the clinical utility of combined sEMG and ROM measurements for assessing the FR phenomenon as a test to assist potentially in planning rehabilitation programs, guiding patients’ individual rehabilitation progress, and identifying early posttreatment outcome failures.

Summary of Background Data. The FR phenomenon has been recognized since 1951, and it can be reproducibly assessed in normal subjects with FR unloaded. It can be found intermittently in patients with chronic low back pain. Recent studies have moved toward deriving formulas to identify FR, but only a few have examined a potential relation between inclinometric lumbar motion measures and the sEMG signal. No previous studies have developed normative data potentially useful for objectively assessing nonoperative treatment progress, effort, or the validity of permanent impairment rating measures.

Methods. In Part 1, 12 asymptomatic subjects were evaluated in an intra- and interrater repeated-measures protocol to examine reliability of sEMG signal readings in FR, as well as ROM measures at FR and maximum voluntary flexion. The mean sEMG signal averaging right–left electrode recordings, as well as the gross, true, and sacral lumbar ROM measurements, were recorded as normative data. In Part 2, 54 patients with chronic disabled work-related spinal disorder referred as candidates for tertiary functional restoration rehabilitation participated in a standardized assessment protocol for sEMG and ROM measurement before rehabilitation. Those who completed the program were retested with the identical methodology after rehabilitation (n = 34) using the empirically derived cutoff scores for sEMG readings at FR and ROM from Part 1 and prior scientific literature. Pain disability self-reported scores were correlated with sEMG and ROM. Sensitivity and specificity of the sEMG for identifying abnormal motion were assessed.

Results. In Part 1, the ability of the experienced testers to measure ROM and sEMG reliably at FR was high (r ≥ 0.92; P < 0.001). All asymptomatic subjects achieved FR at a tightly clustered range of mean sEMG signals from 1 to 2.3 μV. Most of the variation between motion at FR and maximum voluntary flexion occurred through the hip (sacral) motion component of the gross (or total) motion measured at T12. In Part 2, posttreatment reliability for ROM, sEMG, and the ability to detect the FR point was high (r ≥ 0.82; P < 0.001). More than 30% of the 54 patients tested before treatment demonstrated ability to achieve FR, with FR usually associated with higher ROM than in the non-FR patients. After treatment, 94% of those who completed the program achieved FR, including all those who achieved FR before treatment. Flexion–relaxation was associated with major improvement in ROM and pain disability self-report.

Conclusions. Flexion–relaxation measures a point at which true lumbar flexion ROM approaches its maximum in asymptomatic subjects. This also is the point at which lumbar extensor muscle contraction relaxes, allowing the lumbar spine to hang on its posterior ligaments. The gluteal and hamstring muscles then lower the flexed trunk even further by allowing the pelvis to rotate around the hips. This phenomenon was subsequently found in Part 2 to offer a potentially promising method for individualizing rehabilitation treatment, decreasing unnecessary utilization, identifying potential postrehabilitation treatment failures, and assessing permanent impairment rating validity. Moreover, this is the first study to demonstrate systematically that an absence of FR in patients with chronic low back pain can be corrected with treatment.

From the *PRIDE Research Foundation, Dallas, the

†Department of Orthopedic Surgery and the

‡Departments of Psychiatry and Rehabilitation Science, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas.

Supported in part by National Institutes of Health grants 2K02 MH01107, 2R01 MH46402, and 2R01 DE10713.

Acknowledgment date: October 12, 2001.

First revision date: April 8, 2002.

Second revision date: July 26, 2002.

Acceptance date: December 4, 2002.

The manuscript submitted does not contain information about medical device(s)/drug(s). Federal funds were received to support this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence and reprint requests to Tom G. Mayer, MD, 5701 Maple Avenue 100, Dallas, TX 75235; E-mail:

© 2003 Lippincott Williams & Wilkins, Inc.