• Valter Devecchi, Alessio Gallina, Nicola R Heneghan, Alison B Rushton, and Deborah Falla.
• Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK.
• BMJ Open. 2019 Dec 23; 9 (12): e033276.

IntroductionThe course of spinal pain (neck or low back pain) is often described as episodic and intermittent, with more than one-third of people continuing to experience episodic symptoms 1 year after first onset. Although ongoing neuromuscular adaptations could contribute to recurrent episodes of pain, no systematic review has synthesised evidence of ongoing neuromuscular changes in people with recurrent spinal pain during a period of symptom remission.Methods And AnalysisThis protocol is developed and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-P, the Update of the Cochrane Back and Neck Group guidelines and the Methodological Expectations of Cochrane Intervention Reviews. PubMed, Web of Science, MEDLINE, EMBASE, CINAHL, ZETOC, Google Scholar, grey literature sources and key journals will be searched up to September 2019. Observational studies investigating neuromuscular changes in people with recurrent spinal pain during a period of remission will be included. Neuromuscular function will be considered under five outcome domains of muscle activity, spine kinematics, muscle properties, sensorimotor control and neuromuscular performance. Two independent reviewers will search, screen studies, extract data and assess risk of bias (Newcastle-Ottawa Scale). Data will be synthesised per outcome domain. Where clinical and methodological homogeneity across studies exists, a random-effects meta-analysis will be conducted. Otherwise, results will be synthesised narratively. The overall quality of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation guidelines.Ethics And DisseminationFindings of this review may aid the identification of factors that could contribute to spinal pain recurrence and aid the development of interventions for secondary prevention aimed at the restoration of optimal neuromuscular function. The results will be submitted for publication in a peer-reviewed journal and presented at conferences. No ethical approval was required.Prospero Registration NumberCRD42019141527.© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

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