Rabey Martin, Smith Anne, Beales Darren, Slater Helen, O'Sullivan Peter
School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987, Perth 6845, Australia.
Scand J Pain. 2017 Jul;16:22-28. doi: 10.1016/j.sjpain.2017.01.009. Epub 2017 Feb 28.
Provocative pain responses following standardised protocols of repeated sagittal plane spinal bending have not been reported in people with chronic low back pain (CLBP). Potential differing pain responses to movement likely reflect complex sensorimotor interactions influenced by physical, psychological and neurophysiological factors. To date, it is unknown whether provocative pain responses following repeated bending are associated with different pain sensitivity and psychological profiles. Therefore the first aim of this study was to determine whether data-driven subgroups with different, clinically-important pain responses following repeated movement exist in a large CLBP cohort, specifically using a standardised protocol of repeated sagittal plane spinal bending. The second aim was to determine if the resultant pain responses following repeated movement were associated with pain and disability, pain sensitivity and psychological factors.
Clinically-important (≥2-points, 11-point numeric rating scale) changes in pain intensity following repeated forward/backward bending were examined. Participants with different provocative pain responses to forward and backward bending were profiled on age, sex, pain sensitivity, psychological variables, pain characteristics and disability.
Three groups with differing provocative pain responses following repeated movements were derived: (i) no clinically-important increased pain in either direction (n=144, 49.0%), (ii) increased pain with repeated bending in one direction only (unidirectional, n=112, 38.1%), (iii) increased pain with repeated bending in both directions (bidirectional, n=38, 12.9%). After adjusting for psychological profile, age and sex, for the group with bidirectional pain provocation responses following repeated spinal bending, higher pressure and thermal pain sensitivity were demonstrated, while for the group with no increase in pain, better cognitive and affective psychological questionnaire scores were evident. However, these associations between provocative pain responses following movement and pain sensitivity and psychological profiles were weak.
Provocative pain responses following repeated movements in people with CLBP appear heterogeneous, and are weakly associated with pain sensitivity and psychological profiles.
To date, suboptimal outcomes in studies examining exercise interventions targeting directional, movement-based subgroups in people with CLBP may reflect limited consideration of broader multidimensional clinical profiles associated with LBP. This article describes heterogeneous provocative pain responses following repeated spinal bending, and their associated pain sensitivity and psychological profiles, in people with CLBP. These findings may help facilitate targeted management. For people with no increase in pain, the lack of pain provocation following repeated spinal bending, in combination with a favourable psychological profile, suggests this subgroup may have fewer barriers to functional rehabilitation. In contrast, those with pain provoked by both forward and backward bending may require specific interventions targeting increased pain sensitivity and negative psychological cognitions and affect, as these may be may be important barriers to functional rehabilitation.
慢性下腰痛（CLBP）患者中，尚未有关于重复矢状面脊柱弯曲标准化方案后激发性疼痛反应的报道。对运动潜在的不同疼痛反应可能反映了受身体、心理和神经生理因素影响的复杂感觉运动相互作用。迄今为止，尚不清楚重复弯曲后的激发性疼痛反应是否与不同的疼痛敏感性和心理特征相关。因此，本研究的首要目的是确定在一个大型CLBP队列中，是否存在通过数据驱动的亚组，这些亚组在重复运动后具有不同的、具有临床重要意义的疼痛反应，具体采用重复矢状面脊柱弯曲的标准化方案。第二个目的是确定重复运动后的疼痛反应是否与疼痛和残疾、疼痛敏感性及心理因素相关。
研究重复前屈/后伸弯曲后疼痛强度的临床重要变化（≥2分，11分数字评分量表）。对前屈和后伸弯曲有不同激发性疼痛反应的参与者，就年龄、性别、疼痛敏感性、心理变量、疼痛特征和残疾情况进行分析。
重复运动后出现了三组具有不同激发性疼痛反应的人群：（i）两个方向均无具有临床重要意义的疼痛增加（n = 144，49.0%），（ii）仅在一个方向重复弯曲时疼痛增加（单向，n = 112，38.1%），（iii）两个方向重复弯曲时疼痛均增加（双向，n = 38，12.9%）。在调整心理特征、年龄和性别后，对于重复脊柱弯曲后出现双向疼痛激发反应的组，显示出更高的压力和热痛敏感性，而对于疼痛无增加的组，认知和情感心理问卷得分更高。然而，运动后激发性疼痛反应与疼痛敏感性和心理特征之间的这些关联较弱。
CLBP患者重复运动后的激发性疼痛反应似乎具有异质性，且与疼痛敏感性和心理特征的关联较弱。
迄今为止，针对CLBP患者中定向的、基于运动的亚组进行运动干预的研究结果不理想，可能反映出对与LBP相关的更广泛多维临床特征的考虑有限。本文描述了CLBP患者重复脊柱弯曲后异质性的激发性疼痛反应，以及它们相关的疼痛敏感性和心理特征。这些发现可能有助于促进针对性管理。对于疼痛无增加的患者，重复脊柱弯曲后无疼痛激发，再加上良好的心理特征，表明该亚组进行功能康复的障碍可能较少。相比之下，那些前屈和后伸弯曲均引发疼痛的患者可能需要针对疼痛敏感性增加以及消极心理认知和情感的特定干预措施，因为这些可能是功能康复的重要障碍。
