Untitled Notes

Instructor: Diane Dalton, PT, DPT, OCS
Main Focus: Movement Control and impairments related to chronic low back pain (CLBP).

Hodges’ Hybrid Approach: Integrates the Treatment-Based Classification (TBC) and O'Sullivan’s frameworks into examinations and treatments relevant for pain classification.
- Examined layer PIPT (Pain Inhibition and Proprioceptive Training) to inform treatment and assessment strategies.

Physical therapists (PTs) should implement specific trunk muscle activation and movement control exercises for patients with CLBP and movement control impairment (Grade A evidence).
Exercise training, focusing on specific trunk muscle activation, is acceptable for patients with acute low back pain (Grade C evidence).
Approaches like TBC, cognitive functional therapy, or addressing movement system impairment can help reduce pain and disability in CLBP patients (Grade C evidence).
The TBC model is effective in reducing pain and disability for individuals experiencing acute low back pain (Grade B evidence).

Motor Control: Defined as "the way in which the nervous system controls posture and movement to perform a given motor task," including various motor, sensory, and integrative processes (van Dieën et al. 2019).

Systems Theory / Dynamical Systems Theory: Explores how stability relates to balance and motion, emphasizing that different motor solutions are necessary for different situations.
Variability in motor performance is necessary; excessive or insufficient variability can lead to complications.

Optimal Muscle Activation: Ensures appropriate muscle engagement during tasks.
Accurate Sensory Information: Vital for effective motor responses.
Dynamic Control of Movement: Coordination of movement in real-time.
Maintenance of Static Position: Importance of holding positions while minimizing muscle fatigue.

Motor control may demonstrate deviations in individuals experiencing low back pain (LBP). Questions raised include:
- Is trunk muscle activity altered in those with LBP?
- Can these changes in muscle activation reflect the commands from the motor system?
- How do these changes manifest during steady-state postures or movement?

Inhibition of Deep Muscles: Leads to morphological changes in muscle structure over time.
- Increased superficial muscle activity observed during tasks.
- Altered timing of muscle firing noted with delayed contractions of deep muscles and increased activation of superficial muscles in reactive situations.
- Persistent abnormal muscle activation can contribute to recurrent symptoms even after initial complaints subside (multiple studies cited).

Atrophy of Deep Muscles: Decreased cross-sectional area (CSA) in deep muscles, particularly in ipsilateral lumbar multifidus (LM) and transversus abdominis (TrA).
Alterations in muscle fiber types leading to changes in muscle composition over time, including fatty infiltration and fibrosis.

Observations include slower speeds and longer transition phases in movements such as the Sit to Stand Test (STSTS).
Changes in sensory cortex associated with altered proprioceptive strategies; reliance shift from lumbar muscles to ankle muscles alters sway responses.

Observed variability in postural stiffness: some exhibit a loss of stiffness while others have excessive stiffness.
The implications of loading and muscle patterns influenced by varying postural conditions during tasks.

Smudging in Sensory and Motor Cortex: This leads to poorer precision in response to pain and motor tasks.

Studies show variability and redistribution of muscle activation patterns across individuals.
These changes can modify mechanical behavior and lead to adaptations aimed at protecting from perceived threats of injury.
Behavioral responses such as reduced movement and increased splinting can be short-term solutions but may carry long-term negative implications.

Medical Management: Assessment strategy to recognize clinical findings and implement appropriate management based on red flags, medical comorbidities, and neurological evaluations.
Rehabilitation Management: Classification based on psychosocial risk and the presence of predominant leg pain.
Self-Care Management: Strategies directed at low psychosocial risk statuses and primarily axial low back concerns.

Symptom Modulation: Focused treatments for high disability and volatile symptom status, including manipulation, mobilization, traction, and active rest.
Movement Control: Interventions involving sensorimotor exercises, stabilization routines, and flexibility drills for moderate disability issues.
Functional Optimization: Targets low disability with emphasis on strength, conditioning, sport-specific tasks and general fitness.

Movement Impairments: Characterized by fear of movement, hyper-vigilance, muscle guarding, and aberrant movement patterns.
Control Impairments: Marked by anxiety, decreased proprioceptive awareness, loss of functional control, and inability to effectively dissociate lumbar from extremity movement.

Cochrane Review 2016 found benefits from Motor Control Exercises (MCE) for chronic LBP, comparable to other exercise types.
Limited effectiveness found in acute cases with insufficient participant grouping.

Neurodynamic Techniques: Aim to restore stability in and surrounding the nervous system; demonstrated reductions in intraneural edema, improved fluid dispersion, and reversed immune response after nerve injury.

Focus on skill acquisition through enhancing context such as task-based practice, varied repetition, and appropriate feedback mechanisms.
OPTIMAL Theory of Motor Learning: Enhances motor learning through intrinsic motivation and attention, focusing on expected performance success, learner autonomy, and external focus on movement outcomes for improved automaticity.

Strategies to boost self-efficacy through positive feedback, social-comparative techniques, and autonomy-supportive instructional language, avoiding overly directive commands.
External focus on outcomes advances motor efficiency and forms a better coupling between intention and execution.