Lumbar Flexion related pain (in a poor motor learner): Brief Case over view of Sub-classification Functional Mechanism Based Rehab

Referral from another Physiotherapist: Low back pain - seems flexion related but I can't help him. Please assess and see if you can help him.

Intake Questionnaires Prior to first visit

Neuro-immune- Sympathetic-Endocrine (NISE) Screen (predicts systemic / neurogenic inflammation): 12/18 (Note: this is next to the cut point)

Behavioral Screening: Negative

Central Sensitization Screen: Negative

Motor Control Abilities Questionnaire (MCAQ) (predicts ability to learn specific motor control exercise): Negative

Body Image Screening (predicts midline awareness, motor imagery ability and body image pain): Positive

Subjective History overview:

A 37 year old IT office worker with a 10 year history of right sided low back pain following a gym injury while lowering weights. Has had numerous passive therapies over that time frame with no benefit. Stated that "neural flossing" did provide some benefit at the time and has had "motor control" training with no benefit from a therapist that was Kinetic Control and Sahrmann trained. The pain was constant and rated 4/10 (flare up 6-7/10). Sitting and bending were the key aggravating factors.

Given he was positive on the Body Image Screening and negative on the MCAQ I explored that further since I was concerned he would be a false negative on the MCAQ (e.g. predicts he can learn but not actually be able to learn).

Birth History: normal

Development: walked quickly (e.g did not crawl or roll enough)

Handedness: Mixed dominance

Sports: avoided sports as a child because he was not very good

Clinical Reasoning: likely a midline disorder concurrent with lumbar movement control disorder. Body image pain ruled out due to pain pattern. Need to rule out central sensitization.

Physical Assessment Overview

Temporal summation: normal

Pressure pain threshold: mildly reduced locally but not widespread

Standing

Trunk flexion: no hip movement during trunk flexion and was unable to cognitively alter this

One leg standing: positive bilaterally

Midline and neurodevelopmental Assessment

Cross March (for midline and neurodevelopmental disorders): very positive (note figure: left is normal and right is the patient. Can you spot the difference in crossing midline?)

Amphibian for hip flexion development: positive

Sub-classification to direct therapy:

Neurological Factors: CNS Coordination Disorder (cannot learn specific motor control exercise)

Pain Mechanism: local sensitization / primarily mechanical pain

Movement Pattern: Flexion related symptoms

Patho-anatomical: SIJ / L5 right sided symptoms

Treatment Day 1

4 exercises for Neurodevelopmental rehab (note: total pain relief during the Landau; hips were contributing to trunk flexion following the amphibian reflex; the one leg standing test was negative on the left and still positive on the right following the demonstration of the exercises x 2 reps each).

Advise on dietary changes

Day 2 (one week later)

Pain level was 2/10 and not constant (80% of day)

Immediately following treatment reduced his carbohydrate intake to that of his wife who is has type 2 diabetes and started healthier eating

Exercises added: supine creep to alter movement pattern further; lumbar multifidus (could now learn - total pain relief during this exercise); specific lumbar neutral

Clinical interpretation: It is quite likely that some of his local pain sensitization and reduced cognitive function was related to his borderline score on his NISE screen. Therefore, some of his benefit is likely related to reduced systemic inflammation due to his dietary changes. However he did have local pain and the corrective exercises did immediately change his symptoms so there was likely a dual problem.

It is unusual for a poor learner to change as quickly as this, however his original score on the MCAQ was 47. This will need to be confirmed on his next visit in two weeks. He is educated and was very motivated (and compliant). There was a great therapeutic relationship and no adverse beliefs. Assuming he continues to learn specific motor control, the plan will be to progress his exercises to facilitate a more normal lumbo-pelvic rhythm, and lumbo-pelvic stability. He will also be progressed through a dietary regimen for NISE Syndrome regulation.

It does not matter if it is the exercises or the dietary modification that helps this patient. In research one would want to just give one intervention. If I were to do this in a research setting I would have not given him a dietary change because he did not meet the cut off point. A large number of clinical cases I have looked at tell me that people like this (Moderate NISE Sypmtoms) tend to improve but take much longer than a normal time frame.

The key to quickly managing this patient was the sub-classification of lumbar flexion and the mechanism of it being neurodevelopmental. He was not going to respond to standard exercises to cognitively control or alter his movement. He simply could not do it. He never learned how to move properly as an infant or toddler.

Final Note: The patient just emailed me (one week after appointment number 2) to say his pain was much less frequent (20% of the day), still 2/10 and he can control the pain with his exercises (the pain does not flare up)

Want to Learn?

The lumbar spine course is being offered in Calgary, Alberta Canada Nov 24-26, 2017 and in Moncton, New Brunswick Canada Dec 1-3

For further information please email: [email protected]

References

Gibbons SGT 2016 Preliminary development of a clinical prediction rule for specific motor control exercise in chronic low back pain. Proceedings of "Progress in Evidence Based Diagnosis and Treatment": 9th Interdisciplinary World Congress on Low Back and Pelvic Girdle Pain, 31 October - 3 November; Singapore.

Gibbons SGT 2016 What are the functional mechanisms of altered movement patterns during trunk flexion tasks? The need for further sub-classification: A systematic review. Proceedings of "Expanding Horizons": The 11th International Conference of IFOMT. July 4-8; Glasgow, Scotland.

Parfrey K, Gibbons SGT, Drinkwater EJ, Behm DG 2014 Head and limb position influence superficial EMG of abdominals during an abdominal hollowing exercise. BMC Musculoskeletal Disorders. 15:52. DOI: 10.1186/1471-2474-15-52 (Highly accessed)

Gibbons SGT 2011 Neurocognitive and sensorimotor deficits represent an important sub-classification for musculoskeletal disorders – Central Nervous System Coordination. Journal of the Icelandic Physical Therapy Association. 38 (1): 10-12

Gibbons SGT 2011 Neurocognitive and sensorimotor deficits represent an important sub-group for whiplash associated disorders. Fifth International Whiplash Trauma Congress. Aug 24-28; Lund, Sweden. J Rehabil Med 2011; Suppl 50: 23

Gibbons SGT 2009 Cognitive learning and sensorimotor function provide a protective effect from disability in low back pain. Manual Therapy. 14 (S1): S30

Gibbons SGT 2009 Neurological soft signs are present more often and to a greater extent in adults with chronic low back pain with cognitive learning deficits. Manual Therapy. 14 (S1): S20

Gibbons SGT 2008 Retraining of asymmetry in recruitment of transversus abdominis. Orthopaedic Division Review. March/April: 29-34

Testimonial

“I can't recommend Sean Gibbons and Smarterehab courses enough. I have found the sub-classification system to be easy to use and revolutionary in removing a lot of the guesswork in my patient management. The primitive reflex course has been transformative in my practice in that it has wide applicability across a spectrum of conditions that would normally constitute ‘difficult’ patients. I can't recommend these courses highly enough!

Chris Barber MCSP BSc (Hons) Musculoskeletal & Sports Physiotherapist, Director: Advanced Physiotherapy Centres Ltd.

As a clinic owner and have seen a trend in Canadian physiotherapy towards spinal manipulation and needling techniques. While these techniques are valuable, the transformative learning that takes place in a SmarteRehab course is the direction I am dedicated to bringing our profession. As Physiotherapists, if we wish to distinguish ourselves from chiropractors, massage therapists, athletic therapists, osteopaths etc., we need to move away from technique based therapy. Sean is masterful at explaining the complex relationship between Central Sensitization, Central Pain, Sensori-Motor Function and how it relates to Motor Control dysfunction and pain. No other approach I have seen, heard of, or even read about does such a complete job of integrating neurological rehabilitation techniques and orthopaedic treatment. I now have junior therapists who are able to reason their way through the most complex of chronic pain cases and can formulate treatment plans that are effective and get results. Most importantly they can explain to these patients the nature of their problem in a way that they can understand. It is so rewarding to see patients, empowered with this knowledge, resolve problems that have sometimes existed for decades. Equally as rewarding is watching a junior Physio quickly solve an orthopaedic complaint by identifying the underlying movement dysfunction and easily explaining it’s cause. Thank you Sean for what you have done and continue to do for our Profession.

Dave Holmes Owner and Physiotherapist at Tower Physiotherapy & Sports Medicine

If you find yourself stuck and frustrated with chronic, generalized, weird pain patients who don't respond to usual treatments, this is what this course is all about. Sean's courses are truly unique and bring practical, evidence based guidelines that are untouched by other institutions. Places are limited.

Jean-Michel Cormier, Physiotherapist Max Health Institute, Shediac, NB, Canada

Facilitator

Sean Gibbons graduated from Manchester University in 1995. He has been rehabilitating movement patterns for over 20 years. He researched and developed numerous advances to the cognitive control of movement including which postural and primitive reflexes influence movement and key aspects of the neurodevelopmental history. His PhD was on the development of a prescriptive clinical prediction rule for specific motor control exercises in low back pain. Key new sub-classifications were identified: neurocognitive, sensory motor function which is related to extremely poor movement and the ability to learn to coordination exercises; central body image pain and neuro-immune-endocrine dys-regulation. His current work follows this and aims to further sub-classify pain mechanisms and understand the mechanisms of non mechanical pain. His dissection and research into psoas major, gluteus maximus and other muscles has led to the development of new rehabilitation options. He has presented his research at national and international conferences and has several journal publications and book chapters on related topics. He is an Assistant Clinical Professor (Adjunct) at McMaster's Advanced Orthopaedic Musculoskeletal / Manipulative Physiotherapy specialization.