Why Does Back Pain Recur?

Posted by:   Kevin G. Parker, D.C.

written  By Jasper Sidhu, BSc, DC

Why Does Back Pain Recur? New Research Findings and Treatment Considerations

Addressing wasting and dysfunction of the multifidus muscle.


The multifidus muscle has garnered increased attention over the years as an important contributor to low back pain because it has been shown to atrophy following LBP.

Although symptoms may improve, multifidus wasting persists, leading to the premise that recurring low back pain may be due to this lumbar stabilizer.

Treatments directed at normalizing its level of function have been formulated to effectively address low back pain. This has led to an increasing amount of “spinal stabilization” training programs to address multifidus muscle dysfunctions.

…side notes:  3ish minutes YouTube Video of Stuart McGill, a professor of spine biomechanics at the University of Waterloo in Canada, demonstrates a core exercise program that emphasizes all the major muscles that support the spine.[[[[[Video]]]]]]


Related 3ish min video explanation of Why Discs hurt. Way to Go Dr. Snell at FixYourOwnBack.com!

Related 3 min video animation:  How HERNIATED DISCS AND RUPTURED DISCS Heal.

Related article:  Traction effective in promoting repair to degraded disc-Spine 2014

Related article:  The Science of Spine and Joint Health

Related article:  Posture may Predict Future Disability-J Gerontol A Biol Sci Med Sci. 2013

Related article:  Posture Predicts Mortality-Journal of the American Geriatrics Society-October 2004

However, not all “recommended” exercises have proven to be effective.

Let’s explore the latest research findings regarding the role of the multifidus muscle in chronic recurrent low back pain, as well as the value of spinal manipulation and exercise programs you can easily integrate within your practice.

…side note:   Spinal Decompression Case Study with Before and After MRIs

Recurrent LBP: The Role of the Multifidus Muscle

Approximately 34 percent of people who experience acute low back pain will suffer recurrent episodes.1

There are many theories on why some patients experience these episodes while others don’t. One area of thought is the possible loss of normal motor control of the deep muscle fibres in the lumbar spine.

A recent study by MacDonald, et al. (2009) provided some of the first evidence of a connection between altered deep muscle activity and recurrent low back episodes.1

The study assessed whether the control of the deep muscles (multifidus) differed between the normal population and those with unilateral recurrent low back pain. EMG onset of the muscles occurred later in participants with recurrent low back pain than in normal individuals.

Since the multifidus muscle is a stabilizer of the spine, any delay in muscle firing may lead to abnormal biomechanics. If there is a delay in muscle activation, the question arises on whether this is present when unpredictable loading is applied, considering this type of loading is a common injury mechanism for low back pain.

In a second study, MacDonald, et al. (2010) assessed the impact of unpredictable loading on muscle activation and found that both the deep and superficial fibers of the multifidus muscle had less EMG in people with recurrent low back pain than with healthy subjects.2

In addition to altered movement patterns, atrophy of the multifidus has also been demonstrated following episodes of low back pain. Asymmetric atrophy is seen in those with unilateral lumbosacral radiculopathy, which may reflect denervation of the multifidus muscles.3

In patients with long-standing unilateral back pain due to monosegmental degenerative disc disease, selective multifidus atrophy develops on the symptomatic side.4

…side note...Nonoperative Management of Low Back Pain and Lumbar Disc Degeneration -Journal BONE AND JOINT SURGERY 2004

Selective atrophy of the multifidus muscle may also be an important factor in the occurrence of low back pain after prolonged bed rest.5

Treating the Multifidus: Rehab Strategies

Back exercises

Now that we know the effects of low back pain on multifidus function and structure, how do we go about treating it?

Various rehabilitation exercises exist, ranging from low tech to state-of-the-art equipment. We provide the latest research findings into rehabilitation of the multifidus muscle. Utilizing these key principles and findings should help you refine and modify your rehabilitation plan.

Rehabilitation of the multifidus muscle involves several key goals:

1) initiate activities that increase co-activation of the multifidus with the transverse abdominus muscle;

2) normalize motor control of the multifidus and surrounding muscles; and

3) increase hypertrophy, strength and endurance of the affected muscles.6

Although we talk specifically about rehabilitation exercises, one should never forget the importance of spinal manipulation in the care of the patient.

Spinal manipulation has been shown to influence multifidus muscle function, resulting in improved muscular control of the trunk, thereby enhancing the effects of exercise.7-8

Initial exercises should include specific motor control training.

A bed rest study found that although there was no difference in outcomes between a specific motor control and a trunk flexor / general strength program, the specific motor control training program was preferable in restoring the cross sectional area of the multifidus since it limited the potentially harmful compressive forces through the spine.9

Therefore, specific motor training is an effective way to begin a rehabilitation program for someone who may not be able to tolerate more aggressive exercises.

Most clinicians progress the patient to different floor exercises, such as the plank, the bird dog, back extension, back bridge, curl-up and side bridge.

Research shows the activity of the multifidus is greatest during the back bridge exercise.10

The exercise that produced the greatest activity level for the transverse abdominus (to maximize co-contraction with the multifidus) was the elbow-toe (plank) exercise with contralateral arm and leg lift.10

Upper-extremity isometric exercises can also be incorporated. Horizontal isometric shoulder extension elicited an activity level of 84 percent for the multifidus muscle in comparison to a trunk extension exercise.11

Therefore, upper-extremity isometric exercises can be incorporated into a rehabilitation program prior to lumbar extension exercises, allowing for optimal progression of exercises based on muscle activation and difficulty level.

Proper progression of exercises is based on utilizing low-intensity exercises and progressing to those that require more muscle activity. One recent study looked at EMG data for the multifidus muscle, normalized to percent of the maximum voluntary isometric contraction (MVIC).12

The progression from low intensity to high intensity is as follows:

low intensity: bridging / side bridge / upper and lower body raises in either prone or quadruped positions;

medium intensity: prone lumbar extension to neutral / resisted lumbar extension while sitting / prone extension with all extremities lifted (Superman exercise);

high intensity: Prone lumbar extension to end range with resistance applied.

Instead of progressing from a low-intensity exercise to a higher intensity one, utilizing an unstable surface can enhance the effects of an exercise.13

For example, during a plank exercise, progression to lifting of the extremities may be too difficult for the patient. Instead, simply incorporate an unstable surface (rocker board, wobble board, etc.) into the plank exercise to further enhance trunk muscle activity.

Clinicians often utilize a gym ball for exercise progressions. However, the assumption that an exercise ball will increase the challenge to the muscular system was not supported by one recent study.14

Although performing a back extension exercise on a gym ball was no different than performing on a mat for a healthy, young population, the use of a ball produces less spinal loading stresses and may be used in rehabilitation to reduce the potential for re-injury. Therefore, using a gym ball may be more a factor of decreasing spinal loads rather than providing a more challenging exercise.

For prolonged bed rest, vibration exercise has been shown to offset multifidus wasting.15

These findings support the view that initiating vibration exercise in the early stages of rehabilitation may provide an effective stimulus to offset wasting. This is an effective “early adoption” to exercise in the rehabilitation setting.

Lumbar extension machines have shown to be effective in increasing back strength, decreasing pain and accelerating return to work in patients post disc surgery.16

However, adding pelvic stabilization to the lumbar and hip extensor muscles during dynamic back extension increases activity of the multifidus by 51 percent.17

All of the above considerations will allow for proper progression of exercises for patients with chronic recurrent back pain.

However, one study that examined the effects of three different exercise strategies on inducing multifidus muscle hypertrophy18 found that general stabilization and dynamic intensive lumbar resistance training had no significant effect on cross sectional area of the multifidus muscle.

The most critical part of the program was the static holding component between the concentric and eccentric phase of a dynamic resistance program.

Therefore, integration of a static holding component to a stabilization and dynamic strengthening program may be the most effective consideration to prevent multifidus hypertrophy.

The importance of the multifidus muscle cannot be overstated. In addition to traditional chiropractic care, adding an effective rehabilitation program will allow the clinician to address a muscle that is increasingly shown to be a contributing factor in recurrent low back pain.

Other related articles:

Chronic Low Back Pain-Medical Hypotheses Journal 2007

Chronic Spine pain-Journal of Spine 2003-JMPT 2005

Low Speed impacts-Low velocity collisions causing injuries

Foundation Training

No Sit-ups Stuart McGill PhD

Inflamed gut equals inflamed Joints-Cordain-Br J Nutr. 2000

Healing Time of Soft Tissue

Back Pain-Insider Secrets revealed-San Fran Gate 2012

A New Gatekeeper for Back Pain

Why Does Back Pain Recur?

Fibroblast cells in Healing

Fish oil-Neurosurgeon for the Pittsburgh Steelers

Foam Roller for Back Pain

Exercise Makes Us Feel Good-NY Times 2011

Gluten Free Diet helped Nerve Pain-Neurology 2010

Inflammation-13 Tips To Fight Inflammation

Laser Therapy in Rehabilitation-Irvine California

Low Back Pain Studies 2010

Magnesium Deficiency

Muscle Trigger points vs Acupuncture points

Neck pain-Journal of the American Board of Family Practice 2004

Nerve ingrowth into chronic painful disc-Lancet 1997

Nerve Supply of the lumbar disc-JBJS 2007

Omega 3’s-Molecular Neurobiology-January 2011

Omega 3′s and Nerve pain-Clinical Journal of Pain 2010

Self Movement Screen

Sitting-Can sitting too much kill you? Scientific American Jan 2011

This 2 min video is on spinal decompression, but it gives you a good idea of what is happening as the spine decompresses:  – DRX9000 Spinal Decompression Therapy:: Degenerative Disc Disease

If you are suffering from: Sports Injuries, Sprains, Strains, Car accident,  Herniated Disc, Disc Bulge, Degenerative Disc Disease, Neck pain, Headaches, Low back pain, of just want to feel better and have better life performance– please call our office in Irvine, California- at 949.857.1888or visit our website at ADJUST2IT to learn more about Functional Fitness Chiropractic, Sports massage, Myofascial Release, Corrective Exercise, Non Surgical Spinal Decompression, Class IV laser,  and Functional Nutrition.


  1. MacDonald D, et al. Why do some patients keep hurting their back? Evidence of ongoing back muscle dysfunction during remission from recurrent back pain. Pain, 2009 Apr;142(3):183-8.
  2. MacDonald D, et al. People with recurrent low back pain respond differently to trunk loading despite remission from symptoms. Spine, 2010 Apr 1;35(7):818-24.
  3. Hyun JK, Lee JY, Lee SJ, Jeon JY. Asymmetric atrophy of multifidus muscle in patients with unilateral lumbosacral radiculopathy. Spine, 2007 Oct 1: 2(21):E598-602.
  4. Ploumis A, et al. Ipsilateral atrophy of paraspinal and psoas muscle in unilateral back pain patients with monosegmental degenerative disc disease. Br J Radiol, 2010 Nov 16.
  5. Belavy DL, et al. Muscle atrophy and changes in spinal morphology: is the lumbar spine vulnerable after prolonged bed rest? Spine, 2010 Jun 30.
  6. Freeman MD, et al. The role of the lumbar multifidus in chronic low back pain: a review. PM&R, 2010 Feb;2(2):142-6.
  7. Brenner AK, et al. Improved activation of lumbar multifidus following spinal manipulation: a case report applying rehabilitative ultrasound imaging. J Orthop Sports Phy Ther, 2007 Oct;37(10):613-9.
  8. Tunnell J. Needle EMG Response of lumbar multifidus to manipulation in the presence of clinical instability. J Man Manip Ther, 2009;17(1):E19-24.
  9. Hides JA, et al. The effects of rehabilitation on the muscles of the trunk following prolonged bed rest. Eur Spine J, 2010 Jul 1.
  10. Okubo Y, et al. Electromyographic analysis of transversus abdominus and lumbar multifidus using wire electrodes during lumbar stabilization exercises. J Orthop Sports Phys Ther, 2010 Nov;40(11):743-50.
  11. Tarnanen SP, et al. Effect of isometric upper-extremity exercises on the activation of core stabilizing muscles. Arch Phys Med Rehabil, 2008 Mar;89(3):513-21.
  12. Ekstrom RA. Surface electromyographic analysis of the low back muscles during rehabilitation exercises. J Orthop Sports Phys Ther, 2008 Dec;38(12):736-45.
  13. Imai, et al. Trunk muscle activity during lumbar stabilization exercises on both a stable and unstable surface. J Orthop Sports Phys Ther, 2010 Jun;40(6):369-75.
  14. Drake JD, et al. Do exercise balls provide a training advantage for trunk extensor exercises? A biomechanical evaluation. J Manip Physiol Therap, 2006 Jun;29(5):354-62.
  15. Belavy DL, et al. Countermeasures against lumbar spine deconditioning in prolonged bed rest: resistive exercise with and without whole body vibration. J Appl Physiol, 2010 Dec;109(6):1801-11.
  16. Choi G, et al. The effect of early isolated lumbar extension exercise program for patients with herniated disc undergoing lumbar discectomy. Neurosurgery, 2005 Oct;57(4):764-72.
  17. San Juan JG, et al. Effects of pelvic stabilization on lumbar muscle activity during dynamic exercise. J Strength Cond Res, 2005 Nov;19(4):903-7.
  18. Danneels LA, et al. Effects of three different training modalities on the cross sectional area of the lumbar multifidus muscle in patients with chronic low back pain. Br J Sports Med, 2001;35:186-191.

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