Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Apr 18, 2021; 12(4): 178-196
Published online Apr 18, 2021. doi: 10.5312/wjo.v12.i4.178
Slacklining as therapy to address non-specific low back pain in the presence of multifidus arthrogenic muscle inhibition
Charles Philip Gabel, Hamid Reza Mokhtarinia, Markus Melloh, Sébastien Mateo
Charles Philip Gabel, Department of Physiotherapy, Access Physiotherapy, Coolum Beach 4573, QLD, Australia
Hamid Reza Mokhtarinia, Department of Ergonomics, University of Social Welfare and Rehabilitation Sciences, Tehran 0001, Iran
Hamid Reza Mokhtarinia, Department of Physiotherapy, University of Social Welfare and Rehabilitation Sciences, Tehran 0001, Iran
Markus Melloh, School of Health Professions, Zurich University of Applied Sciences, Winterthur 8310, Switzerland
Sébastien Mateo, INSERM U1028, CNRS UMR5292, Lyon Neuroscience Research Center, Université de Lyon, Lyon 69000, France
Author contributions: Gabel CP proposed the concept and outline; Melloh M provided vital input for the manuscript content with specific relevance to NSLBP, physiology, clinical guidelines and current medical management, references and editing of the manuscript; Mokhtarinia HR provided vital input for the manuscript content with specific relevance to NSLBP physiotherapy and rehabilitation, physiology, references and editing of the manuscript; and Mateo S provided specific vital input regarding the neurological perspectives of rehabilitation, physiology referencing and editing of the manuscript; all authors contributed to writing the manuscript.
Conflict-of-interest statement: All authors state that they have no conflict of interest in any areas.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Charles Philip Gabel, BPhty, MSc, PhD, Director, Department of Physiotherapy, Access Physiotherapy, PO Box 760, Coolum Beach 4573, QLD, Australia.
Received: November 27, 2020
Peer-review started: November 27, 2020
First decision: December 24, 2020
Revised: January 18, 2021
Accepted: March 13, 2021
Article in press: March 13, 2021
Published online: April 18, 2021

Low back pain (LBP) represents the most prevalent, problematic and painful of musculoskeletal conditions that affects both the individual and society with health and economic concerns. LBP is a heterogeneous condition with multiple diagnoses and causes. In the absence of consensus definitions, partly because of terminology inconsistency, it is further referred to as non-specific LBP (NSLBP). In NSLBP patients, the lumbar multifidus (MF), a key stabilizing muscle, has a depleted role due to recognized myocellular lipid infiltration and wasting, with the potential primary cause hypothesized as arthrogenic muscle inhibition (AMI). This link between AMI and NSLBP continues to gain increasing recognition. To date there is no ‘gold standard’ or consensus treatment to alleviate symptoms and disability due to NSLBP, though the advocated interventions are numerous, with marked variations in costs and levels of supportive evidence. However, there is consensus that NSLBP management be cost-effective, self-administered, educational, exercise-based, and use multi-modal and multi-disciplinary approaches. An adjuvant therapy fulfilling these consensus criteria is ‘slacklining’, within an overall rehabilitation program. Slacklining, the neuromechanical action of balance retention on a tightened band, induces strategic indirect-involuntary therapeutic muscle activation exercise incorporating spinal motor control. Though several models have been proposed, understanding slacklining’s neuro-motor mechanism of action remains incomplete. Slacklining has demonstrated clinical effects to overcome AMI in peripheral joints, particularly the knee, and is reported in clinical case-studies as showing promising results in reducing NSLBP related to MF deficiency induced through AMI (MF-AMI). Therefore, this paper aims to: rationalize why and how adjuvant, slacklining therapeutic exercise may positively affect patients with NSLBP, due to MF-AMI induced depletion of spinal stabilization; considers current understandings and interventions for NSLBP, including the contributing role of MF-AMI; and details the reasons why slacklining could be considered as a potential adjuvant intervention for NSLBP through its indirect-involuntary action. This action is hypothesized to occur through an over-ride or inhibition of central down-regulatory induced muscle insufficiency, present due to AMI. This subsequently allows neuroplasticity, normal neuro-motor sequencing and muscle re-activation, which facilitates innate advantageous spinal stabilization. This in-turn addresses and reduces NSLBP, its concurrent symptoms and functional disability. This process is hypothesized to occur through four neuro-physiological processing pathways: finite neural delay; movement-control phenotypes; inhibition of action and the innate primordial imperative; and accentuated corticospinal drive. Further research is recommended to investigate these hypotheses and the effect of slacklining as an adjuvant therapy in cohort and control studies of NSLBP populations.

Keywords: Slacklining, Arthrogenic muscle inhibition, Low back pain, Therapy-intervention, Multifidus, Hypothesis

Core Tip: Non-specific low back pain (NSLBP) is the leading problematic musculoskeletal condition for individuals and society. With no consensus definition, depleted lumbar multifidus stabilization is recognized with fatty infiltration and wasting, where arthrogenic muscle inhibition is a probable cause. With no gold-standard therapy, management consensus recommends cost-effective, self-administered, exercise-based multi-modal approaches. ‘Slacklining’ addresses these criteria as an adjuvant therapeutic rehabilitation exercise, rationalized by a hypothesized over-ride of central down-regulatory induced muscle insufficiency. This allows neuroplasticity, normalized neuro-motor sequencing and muscle re-activation for stabilization. Four neuro-physiological pathways are proposed with further research required into the hypotheses and slacklining’s potential NSLBP rehabilitation role.