Research Article - (2021)Volume 9, Issue 4
Adaptations Associated with Non-Specific Chronic Low Back Pain: A Narrative Review
Joshua Brodie Farragher1*
, Gavin Paul Williams2,3
, Adrian Pranata4
, Doa El-Ansary4,5,6
, Selina Parry3
and Adam Leigh Bryant1
Joshua Brodie Farragher, Centre for Health Exercise and Sports Medicine, The University of Melbourne,
Author info »
Background: Non-specific chronic low back pain (NSCLBP) represents a growing global burden. Individuals with
LBP inherently adapt in a variety of ways, across psychological, behavioural and physical domains. However, adaptive
changes (e.g., altered lifting behaviour) may persist, becoming maladaptive, resulting in negative functional
consequences (i.e., persistence of pain, increased disability). Clinical practice guidelines lack specificity to direct the
type of interventions, dosage and treatment duration. A better understanding of how the maladaptive changes seen
in people with NSCLBP relate to meaningful outcomes (i.e., disability, function, quality of life) and defined subgroups
of people with NSCLBP may inform effective interventions. The aim of this review is to investigate the interrelationship
of psychological, behavioural and neuromuscular NSCLBP-related adaptations, and their clinical
significance with respect to disability, function, quality of life and pain.
Methods and findings: Three MEDLINE searches were conducted to investigate the psychological, behavioural and
neuromuscular adaptations in people with NSCLBP. The initial search returned 12972 articles and 238 were
identified for full-text review. A total of 93 articles were included in this review. Psychological and behavioural
maladaptations (i.e., fear-avoidance beliefs) are associated with poorer patient outcomes, whereas there is uncertainty
regarding the impact of maladaptations in the neuromuscular system on important clinical outcomes. Moreover, the
evidence is more supportive of the interrelationship between psychological and behavioural maladaptations than any
interrelation with neuromuscular maladaptations. To date, methodologies designed to assess NSCLBP-related
functional deficits lack ecological validity. Assessment of patients with NSCLBP should focus on psychological and
behavioural domains that relate to an individual’s disability and functional impairments. Individuals with NSCLBP
present with a variety of diverse adaptions that should focus intervention that aligns patient goals and functional
Non-specific chronic low back pain; Adaptations; Neuromuscular; Behaviour; Psychological factors
Non-specific Chronic Low Back Pain (NSCLBP) is the leading
cause of disability worldwide . At least 80% of the population
will experience Low Back Pain (LBP) in their lifetime  and
approximately 5%-10% of those will go on to develop chronic
symptoms . The incidence of NSCLBP has increased by
19.6% since 2006  and the enormity of this burden is
expected to continue to grow with the global increase in the
ageing population number . The growth in NSCLBP is also in
line with a more general rise in chronic disease such as diabetes
 and dementia , but any association with these conditions
remains unclear. Sequelae observed in people with NSCLBP
occur across multiple domains, including psychological,
behavioural and neuromuscular . These changes may be
adaptative (i.e., compensatory changes that decrease one’s
symptoms, allowing better coping in their environment) or
maladaptive (i.e., compensatory changes that increase one’s
symptoms, inhibiting their ability to cope in their environment)
. Importantly, maladaptive changes commonly observed in
people with NSCLBP usually result from negative beliefs and a
poor understanding of the relationship between pain and harm
(e.g., sitting upright despite an increase in one’s symptoms by
doing so) . Initial responses to LBP can be adaptive, but
persistent adaptive behaviours can become maladaptive and
contribute to the transition from acute to persistent pain .
Interventions for NSCLBP are primarily focused on reducing
disability and improving function . This has been a mainstay
focus for almost a century ; however, the treatment approach
has changed dramatically over the past three decades, with the
introduction of the bio psychosocial model [12,13]. Clinical
practice guidelines throughout the world support the use of
exercise therapy and psychological interventions for the
management of NSCLBP . However, guidelines lack detail
regarding delivery mode and specific exercises. This likely stems
from the fact that numerous published interventional studies
have reported minimal between-group effect sizes [15-19],
ultimately leading to conclusions that each modality is equally
effective. The clinical guidelines assert that the NSCLBP
population is heterogenous, however, they provide no current
recommendations as to how to distinguish or manage subgroups
within the broader NSCLBP population . As a result
of these issues, it is difficult for clinicians to apply these
guidelines to people with NSCLBP . Furthermore, there is
an absence of recommendations pertaining to behavioural and
neuromuscular assessments for people with NSCLBP, despite a
large portion of NSCLBP-related literature devoted to these
domains. Finally, the methods used to quantify NSCLBP-related
adaptations are diverse and, in many instances, the clinical
relevance of these adaptations has not been investigated.
Therefore, it is timely to consider the adaptive and maladaptive
changes that occur in people with NSCLBP, with the
anticipation that a better understanding of the clinical
significance of these changes will lead to the development of
better treatment strategies. As such, the aims of this paper are to
i) evaluate the appropriateness and ecological validity of
methods used to identify neuromuscular NSCLBP-related
maladaptations; ii) discuss the nature and inter-relationships of
psychological, behavioural and neuromuscular NSCLBP-related
maladaptations; iii) evaluate the clinical significance of these
maladaptations in relation to meaningful NSCLBP-related
outcomes (i.e., disability, function and quality of life); and iv)
propose a new model for multi-domain adaptations associated
with NSCLBP (Figure 1). In addressing this knowledge gap, this
review provides a narrative overview of the research investigating
Figure 1: Placement holder. Model for inter-related multi- domain maladaptations associated with meaningful outcomes for individuals with non-specific chronic low back pain.
Methods and Findings
A series of literature searches were conducted on MEDLINE
(PubMed) between August 2020 and March 2021. Studies were
included that evaluated the outcomes of fear-avoidance beliefs,
pain self-efficacy, physical activity, lifting and sitting behaviour,
motor weakness, lumbar muscle morphology and motor control
in people with NSCLBP. Peer-review studies involving humans
and available in English were included in the review.
Randomised controlled trials, observational studies, systematic
reviews and meta-analyses were also included as they denote
higher levels of evidence . All other study designs were
excluded from this review. Three separate searches were
conducted. Medical subject heading (MeSH) terms used to
perform the first search were: (CLBP OR Chronic Low Back
Pain OR LBP or Low Back Pain OR Non-Specific Chronic Low
Back Pain OR NSCLBP) AND (kinesiophobia OR fearavoidance
OR self-efficacy OR pain self-efficacy), yielding 1318
articles. MeSH terms used in the second search included: (CLBP
OR chronic low back pain OR LBP or low back pain OR nonspecific
chronic low back pain OR NSCLBP) AND (lifting OR
sitting OR physical activity), yielding 7640 articles. The third
search used MeSH terms including: (CLBP OR chronic low
back pain OR LBP or low back pain OR non-specific chronic
low back pain OR NSCLBP) AND (weakness OR strength OR
lumbar multifidus OR erector spinae OR motor control OR
neuromuscular control), yielding 4014 articles.
In total, the searches returned 12972 articles. After removing
duplicates, 10711 remained. Of the 10711 studies, 538 were not
available in English and 8605 were excluded based on study
design, leaving 2106 for title and abstract review. The first
author reviewed the titles and abstracts for relevance, resulting
in 238 studies remaining for full-text review. As a result of the
full-text review, 93 articles were included in the final review.
Psychological maladaptations are widely reported in people with
NSCLBP [22-24]. Importantly, maladaptive psychological
changes are strongly associated with functional disability [25-27]
and development of chronic LBP .
Pain is one of the most aversive stimuli and, as such, has a close
relationship with fear . Therefore, it is not surprising that
the tendency to avoid painful tasks is a common adaptive
mechanism seen in people with LBP [29,30]. Fear-avoidance
beliefs have been described as both adaptive and maladaptive in
that behaviours adopted in the short-term may be protective but
when sustained in the longer-term, may be deleterious . Fearavoidance
beliefs are generally sustained as a result of
‘catastrophising’ beliefs and negative interpretations of painful
stimuli and their association with harm . In those with LBP,
there is limited evidence to suggest the commonality of these
negative beliefs; however, it is well understood that they are
associated with the persistence of LBP [32-35]. This could
explain why fear-avoidance beliefs are sustained into the chronic
phase of NSCLBP.
The longevity of behavioural adaptations resulting from fearavoidance
beliefs may be responsible for changes in the
neuromuscular system . Whilst it has long been
hypothesised that people with NSCLBP who demonstrate high
levels of fear-avoidance beliefs would demonstrate more
protective behaviours , the evidence pertaining to this is
unclear. Specifically, the uncertainty regarding the relationship
between fear-avoidance beliefs and behavioural changes is partly
due to conflicting results [37-44]. Furthermore, a proportion of
the uncertainty is due to varied assessment methods of fearavoidance
beliefs. For example, there is recent evidence
suggesting that data derived from task-specific fear-avoidance
questionnaires  are more strongly associated with
behavioural changes than data from general fear-avoidance
Whilst a body of literature has investigated the relationship
between fear-avoidance and behavioural changes [37,39-41],
there is a paucity of evidence investigating the relationship with
neuromuscular-related deficits in NSCLBP. Of the muscular
properties investigated, high fear-avoidance beliefs are associated
with reduced lumbar extension strength . The evidence is
conflicting with respect to the relationship between fearavoidance
beliefs and lower limb muscle strength [48,49].
Importantly, studies investigating relationships between fearavoidance
beliefs and NSCLBP-related muscle deficits are in
short supply with considerable measurement variability [48,49]
and small sample sizes . Thus, there is uncertainty about the
relationship between fear-avoidance beliefs and neuromuscular
maladaptations. Furthermore, there is evidence to suggest
neuromuscular maladaptations and fear-avoidance beliefs
contribute to disability independently .
Pain self-efficacy is defined as the belief in one’s ability to
perform painful or perceived painful tasks or movements in
order to achieve a desirable outcome . Self-efficacy beliefs are
modifiable through an individual’s experiences . Indeed,
longstanding improvements in pain self-efficacy have been
identified in people with NSCLBP as a result of education and
exercise . By contrast, it is also possible that experiencing
pain can negatively impact one’s perception of their ability to
perform painful tasks, thereby resulting in lower pain selfefficacy.
Low pain self-efficacy during the acute phase of LBP
could also lead to avoidance of provocative tasks, not because of
fear-avoidance itself, but due to the lack of confidence in their
ability to cope with pain. The continued avoidance of painful
tasks may perpetuate the existence of low pain self-efficacy and
lead to the persistence of LBP. In those with NSCLBP, higher
levels of pain self-efficacy are associated with decreased pain
intensity, reduced disability scores [55, 56] and greater
functional capacity [57-59]. Moreover, low pain self-efficacy and
high fear-avoidance beliefs typically coexist in people with
NSCLBP . Despite greater research emphasis on fearavoidance
beliefs, there is evidence to suggest that pain selfefficacy
is a more important psychological mediator in the
relationship between pain and disability in the NSCLBP
population . Furthermore, pain self-efficacy appears to be a
critical mediator in the relationship between fear-avoidance and
NSCLBP-related outcomes, such as pain and disability .
However, to date, the impact of pain-self efficacy on physical
measures such as muscle weakness, muscle morphology and
neuromuscular control is currently unknown.
Functional behaviours are impacted by pain or the threat of
pain in people with NSCLBP. Physical activity, lifting and sitting
are examples of behaviours that are commonly reported as
problematic in this population [63-65]. Importantly, changes in
these behaviours in response to pain or fear of pain vary
amongst individuals with NSCLBP .
It is a commonly held belief by clinicians that people with
NSCLBP are less physically active than healthy individuals.
Arguably, this belief is attributed to the theoretical fearavoidance
model which indicates that decreases in physical
activity are the result of fear of pain or harm . Indeed,
theoretical models have identified physical inactivity following
the onset of LBP as a perpetuating factor for chronicity .
However, these theoretical models are only partially supported
as there is conflicting evidence to suggest that physical activity
deficits are commonplace in those with NSCLBP [67,68]. One
limitation to our understanding of physical activity behaviours
in people with NSCLBP stems from the outcome measures used
to quantify physical activity that are unable to differentiate
between different types of activities (e.g., walking or lifting).
Therefore, whilst some people with NSCLBP demonstrate levels
of physical activity similar to healthy individuals, they may
actually modify or avoid certain provocative tasks (e.g., lifting).
Indeed, no previous studies have performed time and motion
analyses of people with NSCLBP. Importantly, time and motion
analyses has led to a paradigm shift in the early rehabilitation
phase following stroke [69,70]. The nature and extent of
adaptations to physical activity in NSCLBP need to be
established before appropriate interventions and education can
The heterogenic nature of the NSCLBP population has likely
contributed to findings presented in previous studies that
indicate negligible to no differences in physical activity-related
behaviours compared with healthy control participants. The
avoidance-endurance theoretical model suggests that a
proportion of people with NSCLBP will decrease their physical
activity-related behaviours whilst others will persevere despite
their LBP . Recent evidence supports this model by
demonstrating that people with NSCLBP exhibit avoidance,
persistence or a combination of both behaviours, towards tasks
that reproduce pain . Thus, people with NSCLBP display
considerable diversity in their behaviours relating to physical
activity, thereby supporting the notion that this population is
Lifting is a risk factor for the development of LBP . A
popular belief held by people with NSCLBP, and clinicians is
that a safe lifting technique should be characterised by a
‘straight’ back with movement and force produced from the
lower limbs [74,75]. This squat-lift technique is also commonly
advocated for the prevention of LBP in the workplace ;
however, from a biomechanical and scientific perspective, ‘best’
lifting technique is equivocal [76-78] with spinal load (i.e.,
compression and shear) comparisons between ‘squat’ (i.e., bent
knee and straight back) and ‘stoop’ (i.e., minimal knee bend and
bent back) lifting techniques demonstrating mixed results
[79-82]. Moreover, biomechanical comparisons of lifting
techniques between those with and without NSCLBP have
shown i) considerable variability, and ii) conflicting results with
increased , and reduced to no differences [84,85] in lumbar
range of motion. These inconsistent findings also provide
support to the notion that people with NSCLBP are not
homogenous with respect to their lifting behaviour . Subclassification,
based on observed motor control impairments
(i.e., flexion pattern or active extension pattern), has
demonstrated significant differences in spinal kinematics
between healthy controls and people with NSCLBP, as well as
significant differences between NSCLBP sub-groups .
Therefore, the commonly held community perceptions together
with general clinical recommendations suggesting that there is a
singular ‘safe’ way of lifting are not evidence-based.
Coordination deficits between the trunk and lower limbs during
lifting has also been associated with NSCLBP [88,89].
Individuals with NSCLBP display differences in trunk and lower
limb coordination and reduced movement variability compared
with healthy controls . Coordination deficits extend beyond
the musculoskeletal system as dysfunction of the respiratory
system during lifting has been identified in individuals with
NSCLBP. Specifically, individuals with NSCLBP perform lifts
with greater inhaled lung volume than those without LBP .
The increase in inspired lung volume is associated with
increased spinal stability and requires further thoracic spine
extension [92,93]. Furthermore, altered breathing patterns may
be associated with psychological factors commonly seen in
people with NSCLBP, such as fear and apprehension .
People with NSCLBP often identify sitting as a task that
exacerbates their symptoms . There are two key components
regarding sitting: i) time and ii) posture. Similar to lifting,
clinicians and people with NSCLBP commonly share the
misconception that an upright sitting posture is optimal [95-97].
However, like lifting, there is a lack of evidence to support the
notion that there is a singular ‘best’ universal sitting posture. In
reality, people with NSCLBP tend to adopt sitting positions at
either extreme of range (i.e., lordotic or kyphotic positions)
compared to healthy individuals [98,99]. Adopting end of range
sitting postures is a NSCLBP-related maladaptive trait as
evidence demonstrates that when patients are positioned at the
opposing end of range position or in a more neutral sitting
position, they report reductions in pain intensity during sitting
. When it comes to sitting posture, it is apparent that a ‘one
size fits all’ approach fails to address the complex and highly
specific needs of people with NSCLBP. The evidence relating to
the impact of sitting time on NSCLBP, however, is unclear due
to inconsistencies in the literature [100-104], which likely result
from differences in outcome measures used (e.g., patient
reported measures vs. accelerometry).
Maladaptations within the neuromuscular system including
muscle weakness, muscle atrophy and motor control
impairments, have long been described in those with NSCLBP
[105,106]. Exercise interventions aimed at reducing disability in
people with NSCLBP have targeted these neuromuscular deficits
Adaptations in NSCLBP-related muscle morphology have been
investigated for almost 30 years . These studies have
primarily focussed on the morphology of the lumbar extensors
and trunk muscles given their involvement in lumbar spine
stability [107,108]. Indeed, numerous imaging studies have
reported altered morphology and decreased size of the lumbar
multifidus in NSCLBP people compared to healthy controls
[109-112]. People with unilateral NSCLBP display significantly
reduced multifidus size on the symptomatic side with a
moderate positive relationship with pain duration. However, no
associations with weakness or self-reported disability have been
identified [113,114]. Importantly, these studies have focused on
people with minimal disability and may not be representative of
a more disabled NSCLBP population.
In addition to muscle size, numerous studies have investigated
NSCLBP-related changes in muscle composition. Specifically,
magnetic resonance imaging studies have demonstrated that
people with NSCLBP exhibit increased fat infiltration in their
erector spinae and lumbar multifidus muscles [115-120].
Surprisingly, the severity of fat infiltration in the lumbar
muscles is only weakly associated with the severity of NSCLBPFarragher
related disability [117,118]. Whilst similar to the
abovementioned evidence pertaining to lumbar muscle size, no
studies have investigated relationships between lumbar muscle
morphology, weakness and performance of functional tasks.
Considering the weak associations between lumbar muscle
morphology and disability, it is unlikely that interventions
aimed at augmenting muscle size and composition would yield
clinically relevant improvements in people with NSCLBP
The impact of motor weakness on function in people with
NSCLBP is contentious . Even the existence of NSCLBPrelated
motor weakness is debated in the literature. In this
respect, there are inconsistent findings regarding the presence of
motor weakness in the lumbar extensors of those with NSCLBP
when compared with healthy controls [122-130].
The disparity of findings between studies may be partly due to
the testing methods employed as some protocols limit pelvic
rotation in a seated position [129,130] in order to isolate lumbar
extension , whilst others permit posterior pelvic rotation
[122-128]. Studies that restricted pelvic rotation reported no
difference in lumbar extensor force-output between people with
and without NSCLBP [129,130]. In contrast, six of the seven
trials that did not restrict pelvic rotation found significant
evidence of motor weakness during lumbar extension between
participants with NSCLBP and healthy controls [122-127].
Restriction of pelvic rotation may lack ecological validity. Some
studies have attempted to address this issue by testing lumbar
extensor muscle strength in standing [122,123,126]. However,
this test is ‘static’ in nature and, as such, does not test the types
of isotonic muscle contractions utilised during functional tasks,
such as lifting.
Despite the known involvement of the posterior pelvic rotators
(i.e., gluteal and hamstring muscles) in functional tasks ,
there is a paucity of evidence evaluating them in people with
NSCLBP. Of the single study identified, no difference between a
NSCLBP group and healthy controls was identified .
However, obvious methodological flaws create uncertainty, as
muscle strength testing has been performed i) using manual
muscle testing, which is inherently inaccurate [134,135]; ii) using
maximal effort contractions which are rarely required in day-today
activities, iii) are conducted in non-functional positions (i.e.,
side-lying), or iv) are quantified using isometric contractions that
are not representative of the types of isotonic (i.e., concentric
and eccentric) muscle contractions involved in functional,
closed kinetic chain movements. Therefore, it is not surprising
that neuromuscular impairments including motor weakness
exhibit limited associations with clinical and functional
outcome measures (i.e., disability and functional performance)
given that the testing methods lack ecological validity.
Assessment protocols designed to quantify muscle force output
though coordinated functionally relevant movements are likely
to be more relatable to functional deficits in this population.
Motor control deficits
Motor control is defined as the ability of the central nervous
systems to produce purposeful and coordinated movements
. In people with LBP, motor control deficits have been
described in the literature for decades. A landmark study by
Hodges and Richardson  indicated that spinal stability and
control are altered with LBP. Early studies focussed on the deep
trunk muscles (i.e., transversus abdominus and multifidus
muscles) [137-139]. However, there are conflicting results
regarding differences in recruitment patterns of the transversus
abdominus between those with and without NSCLBP [105,
140-143]. Potential reasons for the disparity between studies may
be due to low participant numbers and differing assessment
methods (e.g., lower-limb tasks in supine , bilateral upper
limb tasks whilst standing  or performing abdominal
drawing-in in a hook-lying position and in supine [140-142]).
Only one study has reported an association, albeit weak,
between improvements in the ability to contract the transversus
abdominus muscle and LBP-related disability .
Motor control deficits have also been explored via other
methods. One prospective cohort study assessed LBP-related
motor control impairments via three different methods. Firstly,
visual observation of thoracolumbar dissociation was used to
assess motor control, but visual observation is inherently
inaccurate. Secondly, passive extension of the lumbar spine was
assessed, but this measures range of movement rather than
motor control. Thirdly, deep muscle contraction, which is
similar to the abovementioned methods, lacks ecological validity
. Overall, none of these clinical tests were able to predict
changes in NSCLBP-related disability or pain over an 8-week
period . In an attempt to implement a more ecologically
valid assessment of motor control, Pranata, Perraton  found
isometric assessment of force control of the lumbar extensor
muscles was predictive of disability level. Whilst this protocol
has some functional relevance in that it examined i) a
provocative task (sitting) and ii) a sub-maximal force output of a
muscle group associated with lumbar spine stability and
movement, data collected in sitting may not translate to other
functional tasks such and walking and lifting. It is apparent that
testing muscle strength and motor control in static, isometric or
non-functional tasks limits the strength of associations with
Maladaptations in multiple domains can lead to disability,
impaired function and health related quality of life for people
with NSCLBP. However, current evidence suggests that
maladaptations in the psychological and behavioural domains
have a greater impact than those in the neuromuscular domain.
Furthermore, the interrelationship between behavioural and
psychological factors is stronger than any interrelationships with
neuromuscular factors. Based on the available evidence, it is
clear that the neuromuscular system is impacted by NSCLBP;
however, studies evaluating the measures of these impairments
have failed to identify meaningful relationships with clinically
important outcomes. This lack of association is arguably
attributed to variability in methods. Future investigation could
consider: i) developing novel ecologically valid tests for
neuromuscular impairments in relation to functional deficits
commonly experienced in NSCLBP; ii) identifying and/or
validating already proposed heterogenous sub-groups within the
NSCLBP population; and iii) if NSCLBP sub-groups exist,
identify discriminating features between them in order to tailor
specific interventions towards these sub-groups. This will more
importantly inform targeted and specific interventions for
There was no funding source for this review.
The authors declare they have no competing interests.
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Joshua Brodie Farragher1*
, Gavin Paul Williams2,3
, Adrian Pranata4
, Doa El-Ansary4,5,6
, Selina Parry3
and Adam Leigh Bryant1
Centre for Health Exercise and Sports Medicine, The University of Melbourne, Melbourne, Australia
Department of Physiotherapy, Epworth Hospital,, Richmond, Australia
Department of Physiotherapy, The University of Melbourne, Melbourne, Australia
Department of Nursing and Allied Health, Swinburne University of Technology, Hawthorn, Australia
Department of Surgery, The University of Melbourne, Melbourne, Australia
Clinical Research Institute, Westmead Private Hospital, Westmead, New South Wales, Australia
Citation: Farragher JB, Williams G, Pranata A, El-Ansary D, Parry S, Bryant AL (2021) Adaptations Associated with Non-Specific Chronic Low Back Pain: A Narrative Review. Int J Phys Med Rehabil. 9:602.
, DOI: 10.35248/2329-9096.21.9.602
Copyright: © 2021 Farragher JB, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.