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Effects of Experimentally Induced Pain and Fear of Pain on Trunk Coordination and Back Muscle Activity During Walking

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Effects of Experimentally Induced Pain and Fear of Pain on Trunk Coordination and Back Muscle Activity During Walking Clinical Biomechanics 19 (2004) 551–563 www.elsevier.com/locate/clinbiomech Effects of experimentally induced pain and fear of pain on trunk coordination and back muscle activity during walking Claudine J.C. Lamoth a,b,*, Andreas Daffertshofer a, Onno G. Meijer a, G. Lorimer Moseley c, Paul I.J.M. Wuisman b, Peter J. Beek a a Faculty of Human Movement Sciences, Vrije Universiteit, Van der Boechorststraat 9, 1081 BT Amsterdam, The Netherlands b Department of Orthopedic Surgery, Medical Center Vrije Universiteit, Amsterdam, The Netherlands c Department of Physiotherapy, Royal Brisbane Hospital and The University of Queensland, Brisbane, Australia Received 3 February 2003; accepted 17 October 2003 Abstract Objective. To examine the effects of experimentally induced pain and fear of pain on trunk coordination and erector spinae EMG activity during gait. Design. In 12 healthy subjects, hypertonic saline (acute pain) and isotonic saline (fear of pain) were injected into erector spinae muscle, and unpredictable electric shocks (fear of impending pain) were presented during treadmill walking at different velocities, while trunk kinematics and EMG were recorded. Background. Chronic low back pain patients often have disturbed trunk coordination and enhanced erector spinae EMG while walking, which may either be due to the pain itself or to fear of pain, as is suggested by studies on both low back pain patients and healthy subjects. Methods. The effects of the aforementioned pain-related manipulations on trunk coordination and EMG were examined. Results. Trunk kinematics was not affected by the manipulations. Induced pain led to an increase in EMG variability and induced fear of pain to a decrease in mean EMG amplitude during double stance. Conclusions. Induced pain and fear of pain have subtle effects on erector spinae EMG activity during walking while leaving the global pattern of EMG activity and trunk kinematics unaffected. This suggests that the altered gait observed in low back pain patients is probably a complex evolved consequence of a lasting pain, rather than a simple immediate effect. Relevance Variability of EMG data and kinematics may explain pain-dependent alterations of motor control, which in turn might con- tribute to a further understanding of the development of movement impairments in low back pain. Ó 2003 Elsevier Ltd. All rights reserved. Keywords: Low back pain; Principal component analysis; Variability; EMG; Trunk coordination, gait; Fear of pain 1. Introduction thorax coordination gradually evolves from more in- phase (synchronous pelvis and thorax rotations in the Low back pain (LBP) is often accompanied by chan- same direction) at lower walking velocities toward more ges in gait, such as a decrease in comfortable walking antiphase (synchronous opposite rotations) at higher speed, step length and swing time (Keefe and Hill, 1985, velocities. Persons with chronic LBP may encounter e.g., Khodadadeh et al., 1988), which may all be related problems in adjusting thorax–pelvis coordination with to changes in trunk coordination (Lamoth et al., 2002b; increasing walking velocity, while at low walking veloc- Selles et al., 2001). In healthy subjects, transverse pelvis– ities a rather rigid locking between thoracic and pelvic rotations may be observed. In contrast, the amplitude of * segment oscillations appears not to be affected by LBP Corresponding author. Address: Faculty of Human Movement (Lamoth et al., 2002b). It is unknown whether these Sciences, Vrije Universiteit, Van der Boechorststraat 9, 1081 BT Amsterdam, The Netherlands. changes in coordination are accompanied by changes in E-mail address: [email protected] (C.J.C. Lamoth). lumbar erector spinae (ES) activity. 0268-0033/$ - see front matter Ó 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.clinbiomech.2003.10.006 552 C.J.C. Lamoth et al. / Clinical Biomechanics 19 (2004) 551–563 Several studies have investigated the effect of noci- able, and that studying the variability properties of ception on motor control, and both increases and coordination patterns may provide insight into under- decreases in muscle activity have been reported (Van lying control structures (e.g., Collins and De Luca, 1994; Die€en et al., 2003). Patients with chronic LBP may Hausdorffet al., 1995; Scholz and Schoner,€ 1999). alter the neuromuscular control of gross motor activities Similarly, in the study of movement disorders the such as locomotion, by way of ‘‘protective guarding’’ analysis of within-subject variability has received con- or ‘‘splinting’’ (e.g., Ahern et al., 1990; Marras and siderable attention in recent years, both for diagnostic Wongsam, 1986). The pain-adaptation model (Lund purposes and with the aim to gain fundamental insights et al., 1991) posits that activity of the agonist is inhibited into pathologic motor behaviour (Donker and Beek, and that of the antagonist augmented to minimize 2002; Hamill et al., 1999; Hausdorffet al., 1997; Vogt movement of the painful segment. This model received et al., 2001). The implication of this development for support from several studies in which acute pain was the present study is that it is deemed important to induced by intra-muscular injection of hypertonic saline. study invariant (global) as well as variable properties For instance, experimentally induced LBP caused in- of movement patterns and ES activity, which, to antic- creased activity of the lumbar ES muscle during the ipate, will be achieved by identifying time resolved swing phase and decreased activity during double stance changes of the overall pattern over repetitions and to when walking, conform to the patterns of muscle activ- quantify its corresponding variability. ity observed in LBP patients (Arendt-Nielsen et al., 1996). Furthermore, experimentally induced LBP caused a reduction in trunk acceleration (Moe-Nilssen et al., 2. Methods 1999). Lamoth et al. (2002b) and Selles et al. (2001) 2.1. Subjects hypothesized that changes in trunk coordination during gait in chronic LBP patients may be aimed at splinting The study was approved by the Ethics Committee of the lumbar spine in order to avoid or reduce pain during the Medical Center of the Vrije Universiteit. Data were walking. However, when this strategy persists beyond collected from 12 healthy university students with no the acute phase, it may sustain pain or lead to new history of LBP or any other musculoskeletal disorder (4 complaints. Current models of chronic pain behaviour women, 8 men; mean age 21 years, range 18–25 years). propose that fear of pain or (re)injury is sometimes more Subjects were paid €45 for their (voluntary) participa- important than pain intensity itself and may contribute tion. After having been familiarized with the protocol, to the emergence or preservation of motor impairments all subjects signed an informed consent form before in LBP (Vlaeyen et al., 1995; Vlaeyen and Linton, 2000). participation. On this perspective, fear-avoidance beliefs are assumed to prevent regain of normal function, promote the 2.2. Experimental design development of guarded movements (Main and Watson, 1996), and lead to disability (Vlaeyen and Linton, 2000). Prior to the walking experiment subjects completed a At present, the relationship between changes in coor- modified version of the Tampa Scale for Kinesiophobia dination patterns and muscle activity observed in LBP (TSK) (Vlaeyen, unpublished report) and the pain ca- patients is not well understood: Do changes in trunk tastrophizing scale (PCS) (Sullivan et al., 1995). The coordination occur directly at the onset of pain and do original TSK (Vlaeyen et al., 1995) was developed for changes in muscle activity occur simultaneously, or are patients with musculoskeletal pain and included state- these changes mediated by the consequences of pain, ments such as, ‘‘It’s really not safe for a person with a such as fear? The present study was performed to help condition like mine to be physically active’’. The modi- resolve these issues by addressing the following ques- fication included a slight change in wording, rendering it tions: (1) Does acute pain elicit changes in trunk coor- applicable to persons without musculoskeletal pain. dination that are similar to those observed in chronic The experiment was performed on a treadmill. Before LBP patients when walking at different velocities? (2) the recording began, subjects walked for a few minutes Does experimentally induced fear of pain in the absence on the treadmill at different velocities to become famil- of actual pain bring about changes in trunk coordina- iar with the treadmill and the experimental setup. The tion?, and (3) Does pain and fear of pain have an impact experiment consisted of four conditions, which were on ES activity during gait? administered in fixed order, but with the second and To date, most studies of walking in LBP patients have third conditions randomised (see below). During focused on global changes in trunk coordination and each condition, all subjects walked for 4 min at four electromyographic (EMG) amplitudes, averaged over successive velocities: 2.2, 3.8, 4.6 and 5.4 km/h, 1 min at strides. In the study of motor control, however, it is well each velocity level, from which the last 30 s were re- recognized that human movement is intrinsically vari- corded. C.J.C. Lamoth et al. / Clinical Biomechanics 19 (2004) 551–563 553 The first condition was normal walking (control increasing intensity and the subject was instructed to condition). Thereafter, in the second and third condition indicate when the stimulus became very unpleasant. subjects walked after intra-muscular (i.m.) injection of Subjects were informed that they would receive, at hypertonic saline in the lumbar ES (pain and fear) and random and without warning, painful shocks that were after i.m. injection of isotonic saline (fear, no pain). between 50% and 120% of the intensity previously rated In human research i.m. injection of hypertonic saline as very unpleasant. Actually, only one stimulus was is a standard method for producing acute experimental delivered at each walking velocity and this stimulus was pain.
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