motor control and low back pain

[Physiodawn]

:rolleyes
I am aiming to better understand motor control and low back pain. I would love to hear comments on the follow topic.

Transversus Abdominis, Diaphragm, multifidus and pelvic floor muscle function may become dysfunctional during an incidence of low back pain.
Once pain has ceased and full functional control of neutral and direction is regained, will normal muscle function be restored or do we need to put emphasis on these in our rehab programs?

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[LloydU]

Dear Physiodawn,

My understanding is that the transversus, because of its anatomy, can help to stabilize the SIJ joint, and as well, help to increase interabdominal pressure. This in turn, helps to stabilize the spine.

Have used General Electrics real time scanning ultrasound unit which shows these muscles in action. An interesting look at the anatomy. Richards et al have written books on the subject.

If you want to contact Lisa Quach at General Electric she can probably tell you about the research and the ultrasound equipment. her e-mail address is lisa.quach@med.ge.com

Sincerely

Lloyd

[somasimple]

Hi All,

When I was looking at the last Olympics games, I saw the weight lifter contest and I didn't see any chocolate tablets as Arnold loved them. I saw bellies with soft tranversus and they lifted it! More than 200kg without any tranversus!
Since 50 years, we are engaged in a core stabilisation which is stabilizing, in fact, the LBP problems without any chance of recovery.

Since two years, I forget to learn my patients such things and it works finer! The recovery is in time activation not strength.

[chunkypuffin]

Hi all,

this is my first post on this forum so hello :-).
Talk about opening a can of worms!! Core stability remains a very confusing subject for myself as well physiodawn, but I would like to make a couple of points:

For a nice overview see Hodges & Lorimer (2003), who work out of University of Queensland where a lot of this physio research is being pioneered.

As somasimple says the crux appears to be primarily in the motor timing of the contractions as opposed to the absolute strength (see work by Hides and/or Hodges). I would raise issue with his observation that no transversus activity was apparent in Olympic weightlifters - surely part of the difficulty in this area is the fact that it is impossible to visually assess the activity of TA!!! A well/ill defined rectus abdominus has little correlation with strength of TA.

Don't forget the role motor and somatosensory remodelling that occur with pain, particularly of a chronic nature. the implications of this upon pain and movement are massive.

Regarding real-time ultrasound I would agree that in some areas this has real benefits, particularly as an assessment and feedback tool. On a personal note, on the single occasion I have used real-time US it was fascinating to note that my "low-level" tonic contraction of TA was actually a near maximal contraction in terms of increased CSA of TA. I now tell my patients to hold the contraction at the point they first feel tension. Again, TA is a difficult muscle to directly,objectively assess.

Don't forget that Core stability involves the complicated interaction of numerous structures and processes and that it is unlikely we will improve our patients by solely activating TA.

Finally, don't forget that as with most areas we are in all likelihood looking at aheterogenous sample with our patients with a multitude of possible pathologies dysfunctions and so some may present with 'core-stability' dysfunction and others mauy not.

Hope that lies well with you all. Anything you disagree with, I'm always keen to learn.

Yours

chunkypuffin

Hodges PW and Lorimer GL (2003). Pain and motor control of the lumbopelvic region: effect and possible mechanisms. Journal of Electromyography and Kinesiology. Vol 13 pp361-370

[Physiobase]

Has anyone yet showed that TA activity is more prevalent in non-back pain suffers than in those with back pain?

I have worked clinically with all type of back pain and was part of the group who co-research and published the UK's 2000 guidelines on the treatment of occupational low back pain. This was an 18 month effort reviewing 3,500 clinical trials, many double blind RCT's. I have not seen anything more than anecdotal evidence about the assume "huge" importance of TA. I would think that the serratus, internal/external obliques, piriformis activity, psoas activity could be given just as much hype. In fact a few simple rotational, flexion and extension back exercises seem to fix the majority of mechanical pain. Are they only working on TA? It's nice to look at the activity with funky technology but how are the ear muscles functioning at the same time? probably not well? Maybe we should train them and back pain would reduce.

I for one appreciate the work on TA but feel it is WAY WAY WAY to isolated in its approach and after all we are a mobile being. We need to move about and our skeletal system is not held together solely by a sustained TA contraction.

Please do comment and or offer studies of relevance.

[chunkypuffin]

hi physiobase,

with regard to your question 'has anyone yet showed that TA activity is more prevalent in non-back pain suffers than in those with back pain?' surely that is the role of the control subjects present in many of these studies. Their data is taken to establish the representative norm for subjects who have not experienced (recent?) back pain. Or am I looking at that too simplisticly? I am in total agreement with you that to isolate treatment towards TA is poor practice, but as a facet of a treatment programme maybe it has use as a 'pre-hab' to avoid further recurrences? Just an idea.

Yours

chunkypuffin

[Physiobase]

Thanks Chunky puffin for your comment. What I would really like to have plainly explained is the actual selection of the control group. How do you get into the control group, no back pain? If it's prevalence is 80% in the normal working population are you not a control awaiting back pain? Does a lack of TA activity occur on the day back pain begins? or would it be likely to be evident pre back pain as a factor causing the back pain? If so, then the control group should have the activation levels as the treatment group with respect to TA. Or is it that back pain inhibits TA activity?

More scrutiny and justification of controls. Who can point us to a great study, with appropriate controls, that looks at several mm groups, and with someone who looks a little further than TA? Does TA works in rotation, whether to stabilize against it or assist/support during rotation? If so why are some teaching a static controlled isometric contractions in supine?

Eccentric control during rotation might be more relevant. This of course would include input/activity every other muscle in the abdominal region. Let's try to broaden our research as it relates more to public health and support for the physio profession.

Studies that show physio treatment is more effective than GP management, better than medication, better than doing nothing, better than ..... are studies we need right now.

Studies that show a thorough 60 minute rehabilitation session for low back pain is better than two 30 minute session once a week is what we need right now. Truth be told I could easily prove from my experience that 10 one hour pilates sessions would do as much if not more than 10 one hour typical "physio" sessions for a client suffering low back pain. This of course includes TA work in conjunction with everything else in the torso. It is more concerned with the restoration or normal, symmetrical movement, something I thank Carr and Shepherd for bring to my attention during my undergrad studies. 8o

[somasimple]

Hi All,

Is it really necessary to bring ever studies that show what we are logically saying?
Abdominal muscles are never activated as we train them! Simply never!

Are we seeing, in normal life, a functional activity where I have my legs up doing some scissors? Does my children think to activate, as we told our patients, their TA while they are playing? Simply no!
And then? Are my children suffering from LBP? No!
Have I a chance to cross in a street a Pilates trainer?

We were told to restore functions but we are simply training some muscles beyond their context!

When needed, I'm using some modified Feldenkrais/Hanna exercises to strength Abs and yesterday a patient was really dubious about its efficacy. It was hard for him to lift the legs up and to breath and I said that he was just lifting the weight of legs! We tried then “my” abs and he pushed 70kg (my weight) without any effort!

It is just logical! We are designed to move as a whole not in parts!

[Physiobase]

Well said Bernard.....I think.....8o

[chunkypuffin]

Hello all,

If I may, I'd like to put forward a few thoughts. As somasimple states, a 'normal' subject does not consciously activate TA (or any other deep stabilising muscle be it multifidus, infra spinatus or whatever) when undertaking a functional movement. Similarly not all people who experience back pain will suffer atrophy of their multifidus/TA or experience altered motor control timing/recruitment patterns. However, SOME WILL. The reason I state this is that I have witnessed these discussions in similar forums and it seems to me that the arguments become increasingly polarised, with both sides increasingly reticent to consider the other camps propositions.

Evidence is available that demonstrates localised atrophy of multifidus post first incidence of low back pain (1,2)(again it may be argued did the LBP cause the atrophy or vice-versa - until longitudinal studies are conducted it will be difficult to know). This same study(1) also identified that NOT ALL subjects experienced this atrophy!!
Further studies have shown that it is possible to train these areas and induce hypertrophy/increased function(3,4) through SPECIFIC STABILISING exercises.

The overall picture appears to be that altered control in trunk musculature is common NOT universal. These alterations may include atrophy and/or temporal alterations in motor control patterns. the return of these muscles to normal function is not automatic. These alterations can be corrected by specific stability exercises which MAY have to be commenced in a non functional situation but would then be graded into more functional positions and actions.

As a relative newcomer to the profession - I qualified as a mature student - I must admit to being somewhat dismayed at the 'all-or-nothing' attitude commonly displayed by many members of the profession. I am sure we can all agree that no single approach or idea could ever prove a universal solution to the problem of LBP, but by utilising the appropriate research at the appropriate time/instance we can hopefully improve the outcomes of our patients.

My apologies if this mail appears abrasive, but while I am far from being in the 'core-stability is all' camp I do feel that we do our patients a disservice by polarising our views and ignoring it totally. As always, if my arguments are invalid I welcome correction - it is a long road to experience and I need all the help I can get :-)

Yours

chunkypuffin

1.Hides J, Richardson C, Jull G (1996). Multifidus recovery is not automatic following resolution of acute first episode of low back pain. Spine. 21(23) pp2763-9
2.Yoshira et al (2003). Atrophy of the multifidus muscle in patients with lumbar disc herniation: histochemical and electromyographic study. Orthopaedics. Vol 26(5) pp493-5
3.Daneels et al (2001). Effects of three different training modalities on the cross-sectional area of the lumbar multifidus muscle in patients with chronic low back pain. British Journal of Sports Medicine. Vol 35 pp186-191.
4.O'Sullivan et al (1997).Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic Low Back Pain With Radiologic Diagnosis of Spondylolysis or Spondylolisthesis. Spine. Vol 22(24) pp2959-67.

[Physiobase]

Again..like with somasimple's comments...well said.

This would be my point. Let's all keep broad minds when researching and more importantly rehabilitating clients with low back pain. It is so easy to focus on one muscle, e.g. VMO in the past on knees, and then to write endless papers about something no one else has written about and therefore become a "Guru". I am only waiting for the day someone does sartorius or popliteus. As you say

I am sure we can all agree that no single approach or idea could ever prove a universal solution to the problem of LBP, but by utilizing the appropriate research at the appropriate time/instance we can hopefully improve the outcomes of our patients.

Now this is the most important thing, to keep the argument balanced. I am in the core camp as long as the core is part of the "Body". I don't profess to be able to tell you exactly what structural change facilitated my patients relief of back pain, but I do know many skills to affect that result. Is that not the important thing? I think we all agree on this.

Healthy debate is great, it keeps us thinking. In fact since rebuilding this forum several months ago I have actually tested several others theory's, sometimes with a positive effect! Now that's the beauty of this exchange. Unfortunately I have an applied maths and physics degree pre my physio training and it always continues to bug at me not only the poor operationalisation of the research questions let alone the statistical methods used to interpret the data. Really I believe the professional needs an appropriately qualified statistical board just as much as an ethics committee, in order to approve funding, grants and experimentation before research is carried out. Now this is a bit off topic but the amount of wasted grant money in the collection of great data but poor conclusion is outrageous! 8o

[chunkypuffin]

physiobase,

couldn't agree more with you about the poor statistical base of some studies. I myself have no background in statistics, and was surprised at how shallow a level we studied it during our BSc. course. The inclusion of statisticians is essential at the planning stage to ensure that sufficient statistical power for a study is attained as well as the validity of susequent data analysis.

Getting back to core stability, does anyone know of any studies investigating the intertransversarii and rotatores? I have read in one McGill article that these small muscles are richly innervated with muscle spindles (up to 8x no. in multifidus). Their role is suggested to be positional sensors more than movement initiators/synergists.This begs the question are they somehow implicated in the dyskinesia seen in LBP subjects? could these muscles become hypo/hyperactive? Just a thought. Look forward to your replies

Yours

Chunkypuffin

[somasimple]

Hi All,

I am also a man of Science and I love mathematics and physics but without being provocative I may add some criticises about statistics and human beings:

1/ Man fits poorly in equations, only crowd does.
2/ Man is unique and statistics are seeking common rules.

About medical studies:
1/ We are trying to prove treatments efficiency and we found the power of placebo.
2/ Technique is quite nothing without a good practitioner.
3/ Study tries to find a technique efficiency and never seek about the practitioner efficiency!

Conclusion =>Enhance practitioner and placebo!

[somasimple]

Statistics: The only science that enables different experts using the same figures to draw different conclusions.
Evan Esar

[somasimple]

Hi All,

A good paper that shows that we must enhance our communication skills...
www.physiotherapy.asn.au/...Potter.pdf

[Back Trainer]

In the past many physical therapists have mistakenly believed that strength is the key to lumbar spine stability. We now know that motor control coordination is actually the key to stability. F. Kermode (who performs research on the deep stabilizing muscles using real-time ultrasound imaging at a physiotherapy clinic in Western Australia) reports that typical back exercise programs, like gym-based rehabilitation program, pool therapy, and Pilates are too advanced for low back pain patients prior to retaining the tonic holding capacity and isolated co-contraction of local muscles, including segmental lumbar multifidus and transversus abdominis.

Evidence (from peer-viewed medical journals, not the anecdotal kind that most PTs embrace here in the USA) suggests that TrA is dysfunctional in all back pain subjects independent of the type or nature of pathology, while subjects who have never had significant back pain do not have this dysfunction (Hodges and Richardson 1996). The dysfunction is related to motor control deficits not strength. Evidence has shown motor control dysfunction in TrA does not return to normal without specific exercise.

Motor control deficits of TrA may include: 1. Failure of a separate low load strategy for TrA control by CNS, 2. Increased recruitment threshold for TrA, 3. Recruitment of TrA becomes dependent upon direction of loading force (similar to global muscles), 4. Onset of TrA recruitment is delayed during limb or trunk movement (as seen during EMG testing studies) when compared to healthy individuals (TrA usually contracts prior to the prime mover of a limb), and 5. Phasic activation of TrA (just thickens the muscle) instead of a tonic TrA contraction that pulls laterally on the medial abdominal fascia to produce a corseting action.

Specific back exercises that focus on deep stabilizing muscles have proven to reverse motor control deficits that occur after back injury or degenerative change. The most significant finding thus far is that patients who receive physical therapy, but do not retrain their deep stabilizing muscles are 12.4 times more likely to have recurrence of back pain within 3 years.

In order to retrain transversus abdominis (TrA), patients are initially instructed to isolate and maintain a tonic contraction separate from the global muscles (e.g., abdominal obliques, rectus abdominis, and erector spinae). This is artificial since TrA contracts along with the global muscles during normal functional activities. But, it is necessary to train this isolated tonic contraction because the central nervous system controls TrA independently of the global muscles in individuals who have never experience back pain. But in dysfunction, this independent control is lost. Therefore, we must reprogram this separate motor control strategy for optimal lumbopelvic stabilization.

Abdominal ‘hollowing’ is a non-functional task that is used to isolate & retrain the mechanical action of TrA pulling on the fascial corset which produces stiffness between individual segments of lumbar spine and pelvis.

This protocol of isolation, training tonic holding ability, training co-contraction of the local muscles, and then integration with global muscles and into functional activities is an effective means of retraining the coordinated function of the local system (Hides et al 1996, 2001, O’Sulivan et al 1997, Richardson et al 1999).” (Diane Lee, The Pelvic Girdle, 2004)

Prognosis and Expected Treatment Times
Acute, first-episode low back pain. The prognosis is good for patients who receive training after first-episode lower back pain. In fact, people who receive no retraining of deep stabilizing muscles are 12.4 times more likely to have recurrence of back pain within 3 years. Those without previous history of lower back pain who present with acute lower back pain needed only 4 weeks of training for a 70% chance of no recurrence.

Chronic, recurrent low back pain. Another study was performed on people with chronic lower back pain (onset of LBP was at least 3 months prior to the study) with a radiologic diagnosis of spondylolisthesis or spondylolysis. They received 10 weeks of training with statistically significant positive results. Specific back exercise training resulted in a decrease in pain intensity and disability. (The control group had no significant change.)

More info at: www.Back-Exercises.com

[Back Trainer]

The Motor Control Approach to lumbopelvic stabilization is not easy to grasp, even if you are a physical therapist. It takes quite a bit of extra study and clinical practice to understand.

Transversus abdominis (TrA) is part of the local system (part of the deep myofascial corset which is part of the deep myofascial cylinder) along with the following muscles that are generally accepted: respiratory diaphragm, transversus abdominis, segmental lumbar multifidus, posterior fasciculus of psoas major, and pelvic floor. More research has probably been performed on the transversus abdominis because it is easily imaged with ultrasound imaging and therefore is a clinically relevant muscle to target. Paul Hodges has done the majority of the important research on transversus abdominis. I would suggest that TrA is a window to local system dysfunction because of certain characteristics that are viewed with real-time ultrasound imaging.

Motor control theory can be simplified as follows:

Your brain may choose from two motor control strategies for stabilization, this is dependant on the amount of load that an activity places on the lumbopelvic region. Contraction of muscles for lumbopelvic stabilization is automatic and dependant on muscle-recruitment threshold: low or high. There is a “low load-bearing strategy” for “normal” (unloaded) functional tasks with low muscle-recruitment threshold and a “high load-bearing strategy” for “loaded” functional tasks with high muscle-recruitment threshold.

In individuals who have never experienced back pain, specific muscles are selected to contract at a low muscle-recruitment threshold for lumbopelvic stabilization during normal activities, whereas other muscles are not used for lumbopelvic stabilization until a higher threshold has been reached during loaded tasks. A low muscle-recruitment threshold means that a muscle is easily recruited during low effort, unloaded tasks. A muscle that has a high threshold will not be recruited for lumbopelvic stabilization until higher effort, loaded tasks.

Scientific studies on individuals who have experienced pain in the region show that the brain stops using a low load-bearing strategy to stabilize the spine and pelvis during normal tasks. Instead, the brain uses the high load strategy for normal tasks (the threshold is lower than normal). Therefore, the brain starts using a dysfunctional motor control strategy for lumbopelvic stabilization after pain is experienced in the lumbopelvic region.

Global muscle over-compensation (which results in co-contraction rigidity) may cause articular degenerative changes from axial compression on the joints of the lumbar spine and pelvis. Physical therapy must focus on down-training global muscle system through relaxation exercises and manual therapy techniques, initially. This is where all the techniques we learned during continuing ed courses will pay off (hopefully).

But, if you do not treat the local muscle dysfunction then your patient is almost guarenteed to experience recurrence of back pain. This should not be ignorantly denied. Physical therapists should embrace the motor control approach and will do well to learn more about these concepts. We really do not have anything else to treat low back pain that has shown efficacy as a treatment technique. Nothing else shows evidence of a decrease in recurrence.

If we do not learn these concepts, someone else will... Or, worse we will continue to do what has always been done because of tradition or because the authoritarian "guru" said that this or that technique will cure pain. Don't confuse the motor control approach with guru therapy. Gurus never have time to do any research (accept anecdotal) because they are so busy developing their concepts to match what they read in a physiology textbook. The development of Motor Control Approach has been through massive amounts of peer-review clinical research using internal EMG, real-time ultrasound imaging, and more.

More info at: www.Back-Exercises.com

[urigellar]

Quote "But, if you do not treat the local muscle dysfunction then your patient is almost guarenteed to experience recurrence of back pain. This should not be ignorantly denied"

SES WHO? All the research trying to relate the two is not the most compelling I have read. Just because motor control research has outweighed manual therapy research in the last 10 years doesnt mean we all have to jump on this bandwagon. Most of the research has been of a very poor standard compared to the much more powerful results that have shown general exercise to be the most beneficial route to a non-recurrence of LBP.

By the way...........in the clinical setting does a valid and reliable way of testing or treating local muscle function exist?

[SuperFizz]

Exactly, general exercise cannot be simplified to one specific technique that has inter and intratherapist validity. This is the point...neither can the human being. You have hit the nail on the head by the fact that something that occurs during exercise affects low back pain in a positive fashion. Trying to isolate that to one thing is proving very difficult and not particularly relevant. We should spend more time on what is the best form of exercise to combat LBP in the general population, of course with the assistance of all manual therapy techniques at our disposal.

:rolleyes

[nickhedonia]

Some sensible words from urigeller and superfiz, for all the weighty evidence in favour or specific "re-training" , one cannot deny that abdominal stregthening regimes done regularly are effective, be they specific with guidance , or just hacked away at by the untrained.
A fatigue resistant core group of muscles ready to accept load when inadvertant strain is felt , would obviously be better than to leave recovery to chance. The difficulty lies with patient compliance to routines requiring skill and sensitivity. The best exercise routine is the one that the patient will actually do, rather than a beautifully crafted regime with written material and an array of detail that is quickly put in the bin.

[somasimple]

Therefore, the brain starts using a dysfunctional motor control strategy for lumbopelvic stabilization after pain is experienced in the lumbopelvic region.

I agree and it's why you can help the brain/patient to restore a functional program. But what is a functional program? Certainly not a localized one!