Hello to all and welcome to my blog
Today we’re going to get stuck into the topical issue of lumbar motor control training.
The assessment and retraining of local or “core” muscles such as transversus abdominis and lumbar multifidus is one of the most commonly used methods for treating low back disorders (LBD) around the world. For detail on mechanisms and clinical application see my article in Physiopedia.
Yet in peer reviewed papers here and here, text books 1, conferences (Peter O’Sullivan’s presentation at IFOMPT 2012) here and of course social media there seems to be a crusade with the aim of bringing down lumbar motor control training.
Why?
The findings of the University of Queensland have not been replicated!
There is some data coming out that varies from the earlier research of Hodges et al. For example Alison et al 2013 have done a series of studies showing that transversus abdominis may not contract bilaterally in response to unilateral postural perturbations.2
However such research does not provide irrefutable evidence that “…training bilateral pre-activation of the transversus abdominis prior to rapid movement is not justified and may potentially be problematic for the production of normal movement patterns.” 3 Rather it opens possible questions around the complexity of motor control. These issues were elegantly discussed by Paul Hodges here.
There are gaps in the motor control literature!
It is true that we do not have a full understanding of the mechanisms underpinning normal and abnormal motor control and that further research is required. However consider what we do know and compare this to our very limited understanding of mechanisms underlying manual therapy or Mechanical Diagnosis and Therapy! The literature supporting mechanisms underpinning a cognitive-behavioural approach have also been questioned of late.4-8 There is substantial biological plausibility supporting lumbar motor control training and this should not be dismissed lightly.
What about hypervigilence and maladaptive beliefs about “stability”!
There certainly are subgroups of patients who require a varied approach to retraining lumbar motor control. And no doubt patients with certain psychological profiles can take the message of engaging the local muscles in daily activity to protect the spine too far. However I suspect this is primarily to do with poor application of motor control training (using strategies such as bracing and exercises such as planks 1) that overload the spinal system too early in the rehab process. Type “lumbar core exercises” into your search engine and you find planks, bird-dog, “dead-bugs”, and fitball exercises dominate – all of which are high level and inappropriate until sufficient motor control of the local muscles is attained. Retraining of the local muscles should always be submaximal (<30% MVC) and prescribed in a manner that encourages and integrates with normal kinematics and fluid/full range functional movement. Such an approach minimises the risk of hypervigilence and maladaptive beliefs.
It is hard to teach
Teaching a patient how to selectively recruit transversus abdominis and lumbar multifidus requires a degree of practitioner skill.9, 10 However clearly described protocols exist11, 12 and most contemporary approaches to LBP involve a significant degree of complexity;13-15 it is a complex condition!16
The randomised controlled trial literature is not supportive!
The strongest level of evidence for the effectiveness of a treatment type is a high quality systematic review. You may be surprised how many physiotherapy treatments (in fact almost all of them) have very limited evidence of effectiveness. However a recent systematic review and meta-analysis showed that:
“The pooled results favoured motor control exercise (MCE) compared with general exercise with regard to pain in the short and intermediate term and with regard to disability during all time periods. MCE was also superior to spinal manual therapy with regard to disability during all time periods but not with regard to pain. Compared with minimal intervention, MCE was superior with regard to both pain and disability during all time periods.”
Bystrom et al. 201317
There is strong evidence supporting the effectiveness of motor control exercises compared to other types of physiotherapy!
The wash up…
Lumbar motor control training is certainly not the be all and end all in treating LBD. However lets not “toss out the baby with the bathwater”. There is strong evidence to support the use of lumbar motor control training. Clinically it makes sense to carefully apply these principles in the context of an integrated approach to LBD. As always rigorous clinical reasoning will ensure that the patient receives treatment specific to their unique combinations of barriers to recovery.
If you’re interested in a free eLearning module on lumbar motor control click here.
I’d love to have a dialogue with the Physiopedia audience so feel free to comment below.
Until next time
Jon Ford
STOPSbackpain.com.au
1. McGill SM. Low back disorders: Evidence-based prevention and rehabilitation 2nd ed. Illinois: Human Kinetics Publishers; 2008.
2. Morris SL, Lay B, Allison GT. Transversus abdominis is part of a global not local muscle synergy during arm movement. Human movement science. 2013.
3. Morris SL, Lay B, Allison GT. Corset hypothesis rebutted–transversus abdominis does not co-contract in unison prior to rapid arm movements. Clin Biomech (Bristol, Avon). 2012; 27(3): 249-54.
4. Simmonds M, Smeets R, Degenhardt B. Pain, mind, and movement. Towards a sophisticated understanding and a tailored clinical approach. Clinical Journal of Pain. 2010; 26(9): 737–8.
5. Hasenbring MI, Verbunt JA. Fear-avoidance and endurance-related responses to pain: new models of behavior and their consequences for clinical practice. Clin J Pain. 2010; 26(9): 747-53.
6. Pincus T, Smeets RJ, Simmonds MJ, Sullivan MJ. The fear avoidance model disentangled: improving the clinical utility of the fear avoidance model. Clinical Journal of Pain. 2010; 26(9): 739-46.
7. Pincus T, Vogel S, Burton A, Santos R, Field A. Fear avoidance and prognosis in back pain. A systematic review and synthesis of current evidence. Arthritis and Rheumatism. 2006; 54(12): 3999-4010.
8. Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. Journal of Behavioural Medicine. 2007; 30(1): 77-94.
9. Standaert C, Weinstein S, Rumpeltes J. Evidence-informed management of chronic low back pain with lumbar stabilization exercises. The Spine Journal. 2008; 8(1): 114-20.
10. Urquhart D, Hodges P, Allen T, Story I. Abdominal muscle recruitment during a range of voluntary exercises. Manual Therapy. 2005; 10: 144-53.
11. Richardson C, Jull G, Hodges P. Therapeutic exercise for lumbopelvic stabilisation: a motor control approach for the treatment and prevention of low back pain. Edinburgh: Churchill Livingstone; 2004.
12. Ford J, Hahne A, Chan A, Surkitt L. A classification and treatment protocol for low back disorders. Part 3: functional restoration for intervertebral disc related disorders. Physical Therapy Reviews. 2012; 17(1): 55-75.
13. O’Sullivan P. Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Manual Therapy. 2005; 10(4): 242-55.
14. McKenzie R, May S. The lumbar spine: mechanical diagnosis and therapy. 2nd ed. New Zealand: Orthopedic Physical Therapy Products; 2003.
15. Maitland G, Hengeveld E, Banks K, English K, editors. Maitland’s vertebral manipulation. 7th ed. Philadelphia: Elsevier; 2005.
16. Ford JJ, Hahne AJ. Complexity in the physiotherapy management of low back disorders: Clinical and research implications. Man Ther. 2013.
17. Bystrom MG, Rasmussen-Barr E, Grooten WJ. Motor control exercises reduces pain and disability in chronic and recurrent low back pain: a meta-analysis. Spine (Phila Pa 1976). 2013; 38(6): E350-8.