Jump to ContentJump to Main Navigation
Show Summary Details
More options …

Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Werner, Mads

CiteScore 2018: 0.85

SCImago Journal Rank (SJR) 2018: 0.494
Source Normalized Impact per Paper (SNIP) 2018: 0.427

See all formats and pricing
More options …
Volume 16, Issue 1


Pain provocation following sagittal plane repeated movements in people with chronic low back pain: Associations with pain sensitivity and psychological profiles

Martin Rabey
  • Corresponding author
  • School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987, Perth, 6845 Australia
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Anne Smith / Darren Beales / Helen Slater / Peter O’Sullivan
Published Online: 2017-07-01 | DOI: https://doi.org/10.1016/j.sjpain.2017.01.009


Background and aims

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.

Keywords: Chronic low back pain; Repeated movement; Pain sensitivity; Psychological; Heterogeneous


  • [1]

    McKenzie R, May S. The lumbar spine: mechanical diagnosis and therapy, vol. 1, 2nd ed. Waikanae, New Zealand: Spinal Publications New Zealand Ltd.; 2003.Google Scholar

  • [2]

    Donelson R, Grant W, Kamps C, Medcalf R. Pain response to sagittal endrange spinal motion. A prospective, randomised, multicentred trial. Spine 1991;16:ps206–12.CrossrefGoogle Scholar

  • [3]

    Hidalgo B, Hall T, Nielens H, Detrembleur C. Intertester agreement and validity of identifying lumbar pain provocative movement patterns using active and passive accessory movement tests. J Manip Physiol Ther 2014;37:105–15.Web of ScienceCrossrefGoogle Scholar

  • [4]

    Fujiwara A, Nohara Y, Kobayashi N, Saiki K. Classifying patients with low back pain: factors aggravating or relieving patient’s symptom. Spine 2010:257.Google Scholar

  • [5]

    Rabey M, Beales D, Slater H, O’Sullivan P. Multidimensional pain profiles in four cases of chronic non-specific axial low back pain: an examination of the limitations of contemporary classification systems. Man Ther 2015;20:138–47.CrossrefPubMedWeb of ScienceGoogle Scholar

  • [6]

    Rusu A, Boersma K, Turk D. Reviewing the concept of subgroups in subacute and chronic pain and the potential of customizing treatments. In: Hasenbring M, Rusu A, Boersma K, Turk D, editors. From acute to chronic back pain: risk factors, mechanisms, and clinical implications. Oxford: Oxford University Press; 2012. p. 485–511.Google Scholar

  • [7]

    Costa L, Koes BW, Pransky G, Borkan J, Maher C, Smeets R. Primary care research priorities in low back pain. An update. Spine 2013;38:148–56.CrossrefWeb of SciencePubMedGoogle Scholar

  • [8]

    Kent P, Keating J, Leboeuf-Yde C. Research methods for subgrouping low back pain. BMC Med Res Methodol 2010;10:p62.Web of ScienceCrossrefGoogle Scholar

  • [9]

    Sahrmann S. Diagnosis and treatment of movement impairment syndromes. St. Louis, Missouri: Mosby, Inc.; 2002.Google Scholar

  • [10]

    O’Sullivan PB. Masterclass. Lumbar segmental ‘instability’: clinical presentation and specific stabilizing exercise management. Man Ther 2000;5:2–12.CrossrefGoogle Scholar

  • [11]

    Long L, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine 2004;29:2593–602.PubMedCrossrefGoogle Scholar

  • [12]

    Long A, May S, Fung T. The comparative prognostic value of directional preference and centralization: a useful tool for front-line clinicians? J Man Manip Ther 2008;16:248–54.CrossrefPubMedGoogle Scholar

  • [13]

    Werneke M, Hart D. Centralization phenomenon as a prognostic factor for chronic low back pain and disability. Spine 2001;26:758–65.PubMedCrossrefGoogle Scholar

  • [14]

    Werneke MW, Hart DL, George SZ, Stratford PW, Matheson JW, Reyes A. Clinical outcomes for patients classified by fear-avoidance beliefs and centralization phenomenon. Arch Phys Med Rehabil 2009;90:768–77.Web of SciencePubMedCrossrefGoogle Scholar

  • [15]

    Edmond S, Werneke M, Hart D. Association between centralization, depression, somatization, and disability among patients with nonspecific low back pain. J Orthop Sports Phys Ther 2010;40:801–10.Web of SciencePubMedCrossrefGoogle Scholar

  • [16]

    Werneke M, Hart D, Cutrone G, Oliver D, McGill T, Weinberg J, Grigsby D, Oswald W, Ward J. Association between directional preference and centralization in patients with low back pain. J Orthop Sports Phys Ther 2011;41:22–31.Web of ScienceCrossrefPubMedGoogle Scholar

  • [17]

    Werneke M, Hart D. Centralization: association between repeated end-range pain responses and behavioral signs in patients with acute non-specific low back pain. J Rehabil Med 2005;37:286–90.PubMedCrossrefGoogle Scholar

  • [18]

    Werneke M, Hart D, Cook D. A descriptive study of the centralisation phenomenon. A prospective analysis. Spine 1999;24:676–83.CrossrefGoogle Scholar

  • [19]

    Hodges P, Smeets R. Interaction between pain, movement, and physical activity: short-term benefits, long-term consequences, and targets for treatment. Clin J Pain 2015;31:97–107.Web of ScienceCrossrefPubMedGoogle Scholar

  • [20]

    Ung H, Brown JE, Johnson KA, Younger J, Hush J, Mackey S. Multivariate classification of structural MRI data detects chronic low back pain. Cereb Cortex 2014;24:1037–44.Web of ScienceCrossrefPubMedGoogle Scholar

  • [21]

    Sullivan MJL, Thibault P, Savard A, Catchlove R, Kozey J, Stanish WD. The influence of communication goals and physical demands on different dimensions of pain behavior. Pain 2006;125:270–7.CrossrefPubMedGoogle Scholar

  • [22]

    O’Sullivan P, Waller R, Wright A, Gardner J, Johnston R, Payne C, Shannon A, Ware B, Smith A. Sensory characteristics of chronic non-specific low back pain: a subgroup investigation. Man Ther 2014;19:311–8.Web of ScienceCrossrefPubMedGoogle Scholar

  • [23]

    Falla D, Gizzi L, Tschapek M, Erlenwein J, Petzke F. Reduced task-induced variations in the distribution of activity across back muscle regions in individuals with low back pain. Pain 2014;155:944–53.PubMedCrossrefWeb of ScienceGoogle Scholar

  • [24]

    Rabey M, Slater H, O’Sullivan P, Beales D, Smith A. Somatosensory nociceptive characteristics differentiate subgroups in people with chronic low back pain: a cluster analysis. Pain 2015;156:1874–84.CrossrefWeb of SciencePubMedGoogle Scholar

  • [25]

    Rabey M, Smith A, Beales D, Slater H, O’Sullivan P. Differing psychologically-derived clusters in people with chronic low back pain are associated with different multidimensional profiles. Clin J Pain 2016;32:1015–27.Web of ScienceCrossrefPubMedGoogle Scholar

  • [26]

    Roland M, Morris R. A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain. Spine 1983;8:141–4.CrossrefPubMedGoogle Scholar

  • [27]

    Wai E, Howse K, Pollock W, Dornan H, Vexler L, Dagenais S. The reliability of determining “leg dominant pain”. Spine J 2009;9:447–53.PubMedCrossrefWeb of ScienceGoogle Scholar

  • [28]

    Reneman MF, Jorritsma W, Schellekens JMH, Göeken LNH. Concurrent validity of questionnaire and performance-based disability measurements in patients with chronic nonspecific low back pain. J Occup Rehabil 2002;12:119–29.CrossrefPubMedGoogle Scholar

  • [29]

    Brouwer S, Reneman MF, Dijkstra PU, Groothoff JW, Schellekens JMH, Göeken LNH. Test–retest reliability of the Isernhagen Work Systems Functional Capacity Evaluation in patients with chronic low back pain. J Occup Rehabil 2003;13:207–18.PubMedCrossrefGoogle Scholar

  • [30]

    O’Sullivan P. Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Man Ther 2005;10:242–55.PubMedCrossrefGoogle Scholar

  • [31]

    Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, Kerns RD, Stucki G, Allen RR, Bellamy N, Carr DB, Chandler J, Cowan P, Dionne R, Galer BS, Hertz S, Jadad AR, Kramer LD, Manning DC, Martin S, McCormick CG, McDermott MP, McGrath P, Quessy S, Rappaport BA, Robbins W, Robinson JP, Rothman M, Royal MA, Simon L, Stauffer JW, Stein W, Tollett J, Wernicke J, Witter J. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain 2005;113:9–19.PubMedCrossrefGoogle Scholar

  • [32]

    Roland M. The Roland-Morris disability questionnaire and the Oswestry disability questionnaire. Spine 2000;25:3115–24.CrossrefPubMedGoogle Scholar

  • [33]

    Kuijer W, Brouwer S, Dijkstra P, Jorritsma W, Groothoff J, Geertzen J. Responsiveness of the Roland/Morris Disability Questionnaire: consequences of using different external criteria. Clin Rehabil 2005;19:488–95.CrossrefGoogle Scholar

  • [34]

    Swanson S, Lindenberg K, Bauer S, Crosby R. A Monte Carlo investigation of factors influencing latent class analysis: an application to eating disorder research. Int J Eat Disord 2012;45:677–84.PubMedCrossrefWeb of ScienceGoogle Scholar

  • [35]

    Sullivan MJL, Thibault P, Andrikonyte J, Butler H, Catchlove R, Larivière C. Psychological influences on repetition-induced summation of activity-related pain in patients with chronic low back pain. Pain 2009;141:70–8.Web of SciencePubMedCrossrefGoogle Scholar

  • [36]

    Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur J Pain 2004;8:283–91.CrossrefPubMedGoogle Scholar

  • [37]

    Dankaerts W, O’Sullivan P, Burnett A, Straker L, Davey P, Gupta R. Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model. Spine 2009;34:1610–8.PubMedCrossrefWeb of ScienceGoogle Scholar

  • [38]

    Vibe Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of classification-based cognitive functional therapy in patients with nonspecific chronic low back pain: a randomized controlled trial. Eur J Pain 2013;17:916–28.CrossrefGoogle Scholar

  • [39]

    May S, Aina A. Centralization and directional preference: a systematic review. Man Ther 2012;17:497–506.PubMedCrossrefWeb of ScienceGoogle Scholar

  • [40]

    Stratford PW, Binkley J, Solomon P, Finch E, Gill C, Moreland J. Defining the minimum level of detectable change for the Roland-Morris questionnaire. Phys Ther 1996;76:359–65.CrossrefPubMedGoogle Scholar

  • [41]

    Dankaerts W, O’Sullivan P. The validity of O’Sullivan’s classification system (CS) for a sub-group of NS-CLBP with motor control impairment (MCI) overview of a series of studies and review of the literature. Man Ther 2011;16: 9–14.CrossrefWeb of SciencePubMedGoogle Scholar

  • [42]

    Smart CB, Staines A, Doody C. Clinical indicators of ‘nociceptive’, ‘peripheral neuropathic’ and ‘central’ mechanisms of musculoskeletal pain. A Delphi survey of expert clinicians. Man Ther 2010;15:80–7.Web of ScienceCrossrefPubMedGoogle Scholar

  • [43]

    Moseley GL, Vlaeyen J. Beyond nociception: the imprecision hypothesis of chronic pain. Pain 2015;156:35–8.CrossrefWeb of SciencePubMedGoogle Scholar

  • [44]

    Zusman M. Associative memory for movement-evoked chronic back pain and its extinction with musculoskeletal physiotherapy. Phys Ther Rev 2008;13:57–68.CrossrefGoogle Scholar

  • [45]

    Van Dillen L, Norton B, Sahrmann S. Classification-specific versus non-classification-specific treatment for people with low back pain. In: 8th Interdisciplinary World Congress on Low Back and Pelvic Pain. 2013.Google Scholar

  • [46]

    Henry SM, Van Dillen LR, Ouellette-Morton RH, Hitt JR, Lomond KV, DeSarno MJ, Bunn JY. Outcomes are not different for patient-matched versus nonmatched treatment in subjects with chronic recurrent low back pain: a randomized clinical trial. Spine J 2014;14:2799–810.Web of SciencePubMedCrossrefGoogle Scholar

  • [47]

    Sheeran L, van Deursen R, Caterson B, Sparkes V. Classification-guided versus generalized postural intervention in subgroups of nonspecific chronic low back pain. A pragmatic randomized controlled study. Spine 2013;38: 1613–25.CrossrefPubMedWeb of ScienceGoogle Scholar

  • [48]

    Saner J, Kool J, Sieben JM, Luomajoki H, Bastiaenen CHG, de Bie RA. A tailored exercise program versus general exercise for a subgroup of patients with low back pain and movement control impairment: a randomised controlled trial with one-year follow-up. Man Ther 2015;20:672–9.Web of ScienceCrossrefPubMedGoogle Scholar

About the article

Received: 2016-08-08

Revised: 2017-01-11

Accepted: 2017-01-25

Published Online: 2017-07-01

Published in Print: 2017-07-01

Funding sources: Martin Rabey was supported by a Musculoskeletal Association of Chartered Physiotherapists Doctoral Award, Chartered Society of Physiotherapy Charitable Trust, Curtin University Postgraduate Scholarship and Australian Postgraduate Award.Darren Beales was supported by a National Health and Medical Research Council of Australia Early Career Research Fellowship. These funding sources had no role in study design; data collection, analysis or interpretation; in writing of this manuscript; or the decision to submit the article for publication.

Ethical issues: All participants gave written informed consent. This research was approved by the Human Research Ethics Committees of Curtin University, Royal Perth Hospital, and Sir Charles Gairdner Hospital, Western Australia.

Conflict of interest: The authors declare that there are no conflicts of interest relating to this manuscript.

Citation Information: Scandinavian Journal of Pain, Volume 16, Issue 1, Pages 22–28, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1016/j.sjpain.2017.01.009.

Export Citation

© 2017 Scandinavian Association for the Study of Pain.Get Permission

Citing Articles

Here you can find all Crossref-listed publications in which this article is cited. If you would like to receive automatic email messages as soon as this article is cited in other publications, simply activate the “Citation Alert” on the top of this page.

Martin Rabey, Anne Smith, Peter Kent, Darren Beales, Helen Slater, and Peter O’Sullivan
Scandinavian Journal of Pain, 2019, Volume 0, Number 0
Jaap H. van Dieën, N. Peter Reeves, Greg Kawchuk, Linda R. van Dillen, and Paul W. Hodges
Journal of Orthopaedic & Sports Physical Therapy, 2019, Volume 49, Number 6, Page 380
Martin Rabey, Michelle Kendell, Chris Godden, Jermaine Liburd, Hayley Netley, Ciaran O’Shaughnessy, Peter O’Sullivan, Anne Smith, and Darren Beales
European Journal of Pain, 2019, Volume 23, Number 4, Page 823
Roy La Touche, Marcos Pérez-Fernández, Ignacio Barrera-Marchessi, Ibai López-de-Uralde-Villanueva, Jorge Hugo Villafañe, María Prieto-Aldana, Luis Suso-Martí, and Alba Paris-Alemany
Journal of Back and Musculoskeletal Rehabilitation, 2018, Page 1
Peter B O’Sullivan, J P Caneiro, Mary O’Keeffe, Anne Smith, Wim Dankaerts, Kjartan Fersum, and Kieran O’Sullivan
Physical Therapy, 2018, Volume 98, Number 5, Page 408
Michelle Kendell, Darren Beales, Peter O’Sullivan, Martin Rabey, Jonathan Hill, and Anne Smith
Journal of Physiotherapy, 2018

Comments (0)

Please log in or register to comment.
Log in