I attended a lecture with guest speakers Jon Ford and Rob Laird to learn about their perspectives on the current research on motor control for treatment of the lumbar spine.
Both speakers placed emphasis on the fact that we are going through an 'anti-motor control' phase due to the controversy which exists in the available research trials. They individually discussed their thoughts about the quality of the research available, the limitations and errors in these trials and justification for why we may not yet have found motor control to be statistically and clinically superior to general exercise in the treatment of lower back pain.
Both Jon and Rob shared their beliefs about how the research translates into clinical practice and what impact it might have on the way physiotherapists currently assess and treat patients with lower back pain. These thoughts are summarised below.
Discussion point # 1: Terminology
Core stability is not a helpful term.
Core stability is not the term that was originally used to describe motor control. This term has been adopted by the fitness industry and is often leading to confusion about what we are trying to achieve with exercise rehabilitation.
Don't forget that motor control describes all aspects of control including muscle function, central processing, and sensory inputs. Motor control describes both normal and abnormal movement patterns.
Motor control isn't specific isolated muscle retraining. It is an approach that leads to normalisation of movement patterns while managing kinematics and contributing factors. It is very complex and individualised to each patient. Many of the faulty beliefs and misinterpretation have come from oversimplification of a complex topic.
An important question Jon asked of the audience was "Do we even know how motor control was meant to be used when first created?" Maybe we could improve our understanding and teaching of motor control at in both the teaching of patients and clinicians?
Discussion point # 2: Effectiveness of motor control exercises
Evidence demonstrating the effectiveness of motor control exercises compared to general exercise for the treatment of lower back pain still doesn't favour motor control.
Jon's crew however have been conducting the STOPS trial (Specific treatment of problems of the spine) and their preliminary evidence is showing that specific motor control is better when used in patients who have low tone and reducible discogenic lower back pain. Thus suggesting that being able to accurately subgroup and diagnose patients will lead to better results from more appropriate application of treatment techniques.
We can't forget that many patients with lower back pain will have a pathoanatomical problem that requires consideration. Some have a clear mechanism and not everyone should be classified as non-specific lower back pain.
Even though research is emerging which provides a framework for classification of non-specific lower back pain, you must remember that there isn't a lot of evidence saying we must disregard the pathoanatomical model. Physiotherapists are being pushed towards a biopsychosocial framework for patient care, and sometimes we are overlooking those who need specific consideration...
To highlight some key points made at the conclusion of Jon's presentation:
"Nothing in science is ever certain but we should not just highlight the disagreement but also talk about the agreement."
"Practitioners need to be able to take all schools of information and be able to thoroughly assess the patients and apply the evidence to them. Motor control training is effective when used in certain patients."
"A treatment approach is never a substitute for good assessment and clinical reasoning skills.
The consensus out weighs the disagreement in research but further research is needed....."
Discussion point # 1: Sub-grouping patients
The great dilemma.
The whole domain of lower back pain research is filled with controversy. Many are starting to believe that the controversy exists because research methodology doesn't account for the heterogeneity of patients with back pain.
Most would agree that lower back pain is not a homogenous group of patients, making diagnosis challenging. There is difficulty and disagreement in both diagnosis and management of back pain, which is reflected both in research trials and clinical practice.
Aside from this though.... from the research that has been conducted, do we know what are normal and abnormal lumbopelvic kinematics? Do we know which movement patterns are clinically relevant? And, does our intervention change these movement patterns?
Subgrouping can assist in accurately identifying patients and this may lead to better application of interventions. Some of the subgroups we can use include: pathoanatomical, psychosocial, treatment type response, and movement patterns.
Discussion point # 2: Where versus why
Rob's research and clinical approach provides a model for diagnosis based on identification of movement or motor control impairments, which then leads to a specifically targeted direction preference treatment. This classification identifies why patients have pain with the underlying belief is that 'unusual movement patterns drive pain.'
The key clinical concepts for movement control dysfunction relating to pain include:
- End range joint position and loading.
- Load and muscle activation.
- Restricted movement.
- Poor proprioception.
But... identifying these patterns for movement and diagnosing patients fundamentally comes from our ability to assess patients and measure responses.
- Postural patterns
- End range flexion
- End range extension
- Excessive muscle tone with increased load.
- We struggle to address postural patterns because they are very hard to measure.
- Flexion movement pattern
- Flexion relaxation response
- Refers to the ability of lumbar erector spine muscles to relax drying the flexion movement.
- Muscles that do not switch off will become over active and their activity will double + the compressive forces going through the lumbar spine.
- Rotational patterns
- Functional patterns e.g. sitting posture and tasks during the day.
Even though there is research which evaluates a mechanisms-based classification for back pain (O'Sullivan classification), there is no comment about the change of movement patterns associated with the improvement of pain? This is where Rob Laird's pilot trial is focussing now, to evaluate movement retraining on actual change in movement, not just change in pain....
Here are some references on this topic:
- Vibe Fersum, K., O'Sullivan, P. B., Kvåle, A., & Skouen, J. S. (2009). Inter-examiner reliability of a classification system for patients with non-specific low back pain. Manual therapy, 14 (5), 555-561.
- Dankaerts, W., & O’Sullivan, P. (2011). 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.Manual Therapy, 16(1), 9-14.
- Laird, R., Kent, P., & Keating, J. (2012). Modifying patterns of movement in people with low back pain–does it help?. BMC Musculoskeletal Disorders,13(169).
- Nelson-Wong, E., Alex, B., Csepe, D., Lancaster, D., & Callaghan, J. P. (2012). Altered muscle recruitment during extension from trunk flexion in low back pain developers. Clinical Biomechanics, 27(10), 994-998.
- Gallagher, K. M., Nelson-Wong, E., & Callaghan, J. P. (2011). Do individuals who develop transient low back pain exhibit different postural changes than non-pain developers during prolonged standing?. Gait & posture, 34(4), 490-495.
It was fantastic to be present for this discussion held by two of Melbourne's leading researchers and specialist physiotherapists in the field of lower back pain. Neither of the speakers had an agenda to push their own research or try persuade physiotherapists to follow their clinical approach. Instead both Jon and Rob provided insight into the limitations and application of research and valid discussions points around why we must remain open minded in our clinical practice. They are both passionate about teaching and sharing their knowledge and expertise with others to improve the skills of those working around them in the profession.