LBP Motor Control & Functional Optimization

Panjabi Model - Active Sub System

Muscle synergies & force capacity to move & stabilize spine

Panjabi Model - Passive Sub System

Ligamentous structure’s ability to stabilize a segment

Disc, facet joints, & ligaments

movement control stage of treatment is a sector of

managing impairments

Panjabi Model - Neural Subsystem

Combination of peripheral & central control mechanisms

Proprioceptors in muscle & ligament provide information

Spinal Cord Reflexes may cause muscle excitation or inhibition

Sensory Motor Cortex interrupts that information & responds w/ changes in muscle activity

The ability of passive, active, & neural subsystems to resist deformation from forces acting on spine

Trunk Stability

The regulation of movement by the active & neurologic subsystem

Motor Control

Muscular performance and ability to generate or resist forces

Strength, power, endurance

Core Strength

Muscle Capacity

pts w/ recurrent & chronic LBP experience changes in active sub system (muscles), for example lumbar

unilateral multifidus experiences atrophy & fatty infiltrate (Fiber type I -> II Chronic)

pts w/ acute LBP experience changes in transverse abdominis & lumbar multifidus, they tend to work

less

pts w/ acute low back pain experience changes in erector spinae, they tend to work

more

there is a small association of lumbar multifidus fatty infiltration with degree of

lumbar disc degeneration

lumbar multifidus atrophy is also associated w/

thigh muscle injuries because of lack of stability of spine (other muscles try to compensate)

Patients with Chronic Low Back pain have

Spinal stiffness (adaptive shortening)

Less variety in muscle recruitment patterns

Acute to Chronic: Changes in trunk muscle activation with

anticipatory & compensatory reactions of trunk musculature w/ perturbation

Acute to Chronic: Changes in Motor Control have Increased and decreased

muscle function variability during fatigue protocols

pts w/ acute LBP have Changes in Neural Sup-System including reduced

corticomotor & spinal cord excitability in areas that related to trunk muscles

pts w/ acute LBP have Changes in the Neural Sup-System including decreases in

Proprioception

Corticomotor & somatosensory “smudging” (homunculus)

Less defined section of M1 for trunk muscles

neural tension can limit ROM, so tx is

neural mobilization (if sxs are aggravated, reclassify patient into symptom modulation approach)

joint stiffness can limit ROM so tx can be

manual therapy: manipulation & mobilization

soft tissues may inhibit ROM so tx can be

MT for soft tissues, passive stretching & soft tissue mobilization

in research pts variables that Predicted Success in motor control tx for LBP

Age <40

Average SLR >91 degrees (hyper mobile)

Aberrant Movements

Positive prone instability test

pt is prone, legs off table, PT presses on LB, if pain produced then they lift their legs & pain reduces this is indicative of a

positive prone instability test (indicates pt will respond well to stability training)

Analysis found 2 items were most predictive of positive reaction to lumbar motor control tx if pt has

Positive Prone Instability Test

Presence of Aberrant Movements

Pain is felt during a specific point or a range during motion

painful arc

during forward bend, a quick acceleration & deceleration w/ or w/o a quick deviation & return from sagittal plane. It can be one discrete event or a series of quick events resulting in

Instability Judder/Catch

Thigh climbing with hands on return from forward bend

Gower’s Sign

Reversed or altered lumbopelvic rhythm during forward bending will show

hip motion greater than lumbar spine motion during 1st 1/3 of mvmnt &

Lumbar spine motion is greater than hip motion during last 1/3 of mvmnt

Reversed or altered lumbopelvic rhythm when Return from forward bending:

Lumbar spine motion is greater than hip motion during 1st 1/3 of mvmnt

hip motion is greater than lumbar spine motion during Last 1/3 of motion

pts who did not have back pain generated spinal stiffness thru

Lat Dorsi, Lumbar Erector Spinae, Lumbar Multifidus

Thoracic Erector Spinae & Glute Max

pts with LBP generate stiffness thru

Thoracic Erector Spinae, Hamstrings

Individuals with low back pain use

less local stabilizers to generate spinal stiffness.

tx for chronic lumbar pain

4 weeks nmes followed by lumbar exercise

Motor Control Treatment goals

Decrease co-contraction

Increase isolated muscle activation & mvmt variability

Encourage activities that move spine in non-threatening ways

Expose person to movements that they avoid

w/ physio ball roll outs, maybe cue a topdown approach

“start" with your head roll your shoulders”

abdominus training

abdominal drawing in

multifidus training progression

unilateral prone leg lifts, bird dogs, superman’s, kettle bell swings

Hypersensitivity to stimuli, Responsiveness to non-noxious stimuli. Increased pain response evoked by stimuli outside area of injury, an expanded receptive field.

Definition of Central Nocicplastic Pain

• Widespread pain

• Pain does not follow anatomical pattern

• High psychological distress

• Pain disproportionate to provocation & easing tests

• Hypersensitivity to light touch

Central Sensitization Disorders

Address social & psychological drivers of pain condition, Emphasis on improving function, Reduce emphasis on biomedical approaches, Motivational Interviewing, Emphasis on patient discovery

Psychologically informed physical therapy

Central Sensitization and Low Back Pain pts are usually

highly medicalized & may have a large number of comorbidities