L10: Motor control Flashcards
Control of _____ orientation to maintain overall spinal position
spinal
Control of ______relationship of lumbar segments and pelvis
inter-segmental
Spinal motor control requires muscle _____, _____, _____ and awareness of movement
strength, endurance, co-contraction
Motor control is not just about spinal stability and strength – but the ability to move in a _____ and _____ way
relaxed; unguarded
What are 3 things that need to be observed/considered to check the ability to move in a relaxed and unguarded way?
- Strength & control
- Overactivity/bracing/hypervigilence
- Awareness of movement
What are the 4 features in functional motor control?
What are 3 roles of the global muscles?
- Action is specific
- Generation of torque, power and motion
- Maintains postural orientation
What are some examples of global muscles?
Eg. abdominals, muscles that attach to the thoracolumbar fascia, erector spinae
What are 4 roles of local muscles?
- Maintains continuous low level activity
- Anticipatory
- Switch on before movement –> Can lose original function
- Not direction specific
- Recruited most effectively in neutral spine
What are 2 examples of local muscles?
Multifidus transversus
What are the 4 functions of transverse abdominis?
- Anticipatory prior to limb movement
- Increases intra-abdominal stiffness
- Important in pelvis and lower back
- Activates in conjunction with pelvic floor to provide force closure at pelvis
- Timing delay in LBP &pelvic pain
What are the 5 functions of multifidus?
- Deep and superficial fibres - Deep fibres contribute to TLF
- Anticipatory action in upper limb movement
- Co-contraction with Transverse Abdominus
- May contribute to sacral force closure with pelvic floor
- Atrophy and delay in LBP
What are 7 relevant global muscle groups to motor control, which contributed to force closure in the lower back ?
EXAM QUESTION
- Iliopsoas
- Glute Max
- Glute Med
- Erector Spinae
- Quadratus Lumborum
- Superficial Abdominals
- TFL, Adductors, Hamstrings
What are 3 reasons why motor control is relevant?
- Changes in muscle function are associated with injury and pain
- Changes may precede or follow acute injury
- Acute adaptation and chronic changes can occur (adaptive/ maladaptive)
What are 4 specific changes which require motor control?
- Delayed, reduced or altered activation
- Enhanced / augmented activity (individual patterns)
- Altered movement patterns
- Altered muscle morphology
What is a source of pain in LBP (relationship between LBP and muscle system)?
Muscles can be a source of pain in LBP
What is a flexion-relaxation like in LBP (relationship between LBP and muscle system)?
Loss of relaxation response in those with chronic LBP
What are the gait alterations like in LBP (relationship between LBP and muscle system)?
Reduced thoracic movement in LBP (Less mvt and pelvis and LB)
What is the potentially compromised balance like in LBP (relationship between LBP and muscle system)?
‘Increased stiffness’ to external perturbations
Less control of external perturbation –> less flexibility to absorb those forces
What is the altered loading like in LBP (relationship between LBP and muscle system)?
Increased loading taken by Lumbar compared to Hips in LBP
Tends to take more load in lower back
What are the incontience and breathing disorders in LBP (relationship between LBP and muscle system)?
Stronger association with LBP than obesity and physical activity – considered likely due to limited coordination of trunk muscles
Affects functional of plevi floor and force closure function –> relationship with LBP and incontience
What is the problem with a lot of people who have LBP and lean forward?
Loses ability to switch off the muscles at end range in the back (increased muscle activity)
Do you see a drop in EMG with LBP?
Don’t see a drop in EMG with LBP
What is Multifidus Acute LBP (relationship between LBP and muscle system)?
Wasting within 1-2 days CLBP with fatty infiltrate, altered activation. Indicative of level
What is muscle wasting in LBP (relationship between LBP and muscle system)?
Paraspinal muscles are smaller in patients with chronic LBP (than in healthy individuals of similar age
What is increase muscle activity in other groups in LBP (relationship between LBP and muscle system)?
Demonstrated increased hamstring, ES and GMax activity during trunk movement efforts
Does rehab help (relationship between LBP and muscle system)?
Despite undertaking muscle rehabilitation for LBP, most studies indicate that muscle function remains unchanged
What are the 5 muscle groups relevant in LBP?
- Abdominals
- Multifidus
- G max
- Iliacus
- Erector spinae
What is affected in the deep abdominals in LBP?
reduced strength, endurance & activity
What is affected in the superficial abdominals in LBP?
increased activity (obliques and superficial groups)
What is affected in multifidus in LBP?
Reduced activity, delay & wasting
What is affected in G max in LBP?
- Reduced endurance and delayed (associated with earlier Hamstring in SIJ pain)
- Increased activity on lumbar flexion movement (with Hamstring)
What is affected in iliacus in LBP?
Reduced strength and/or endurance
What are 5 common myths?
- Motor control and LBP are related to single muscle activation issues
- Does not lead to better outcomes –> not effective (research)
- Targeting individual muscles has carry over into functional tasks
- Thus, need to progress quickly to functional tasks as training individual muscles do not carry over to functional tasks
- Weak abdominals lead to instability and back pain
- Training individual trunk muscles changes their timing and endurance over time
- Poor motor control or muscle weakness is a ‘risk factor’ for back pain
- Try to get as functional as possible with loading –> training non functional tasks won’t help
Very-low to low quality evidence showed MCE ____ (>/
>
Moderate to high quality evidence suggesting no difference between MCE, (with or without) manual therapy, and other exercise. What does this say about motor control?
Manual therapy is not very effective so having or not having it makes no different
Most research show that motor control exercise is not any more effective than the other
______ therapy is effective in decreasing pain and improving function however there is not one form that is more effective than another.
Exercise
Exercise effects are greater when exercise is implemented well (individually designed/Personal preference and ____ (high/low)dose).
high
What are the international guidelines for exercise and lower back pain?
“Given the minimal evidence that MC exercise is superior to other forms of exercise, the choice of exercise for chronic LBP should probably depend on patient or therapist preferences, therapist training, costs and safety”
_____ is effective for LBP and persistent LBP – exercise choice should depend on patient preferences. For all patients with LBP – not one type is more effective than another
Exercise
beneficial effect for _____ and coordination/stabilisation exercise programs over other interventions on LBP.
strength/resistance
motor control retraining _____ (does/does not) equal changes in muscle size/changes in atrophy.
does not
we should consider ______ changes that occur with exercise – not just muscle changes. Give examples
central
Getting better in exercise but not improved eg. strength = improving in other ways
Improving confidence, tolerance, sensitivity, psychosocial effects
When is it relevant to assess motor control and/or use it as a management approach?
- Only certain ‘subgroups’ of patients will benefit from motor control/stabilisation exercises.
- We should try to determine their likelihood from the interview
- Patients with NSLBP and perceived instability (≥9) on a 15-item questionnaire (Lumbar Spine Instability Questionnaire) respond more favourably to MCE than to other exercis
- Can use a questionnaire and then assess motor control Usually athletes
What do normal groups benefit from in exercise for LBP improvements?
Other groups will benefit more from graded – general exercise including weight training.
What are questions in the lumbar spine instability questionnaire?
Note – this is not ‘diagnostic’ – rather a predictor of who will benefit from MCE
- I feel like my back is going to “give way” or “give out” on me
- I feel the need to frequently pop my back to reduce the pain
- I have frequent times when my pain occurs throughout the day
- I have a past history where my back catches or locks when
- I twist or bend my spine I have pain when I sit to stand or stand to sit
- I have a lot of pain when I sit up from lying down if I don’t rise up the right way
- My pain is sometimes increased with quick, unexpected, or mild movements
- I have difficulty sitting without a back support such as a chair and feel better with a supportive backrest
- I cannot tolerate prolonged positions when I can’t move
- It seems like my condition is getting worse over time I have had this problem a long time
- I sometimes get temporary relief with back brace or corset
- I have many occasions when I get muscle spasms
- I sometimes am fearful to move because of my pain I have had a back injury from trauma in the past
What is important to note when using the Lumbar Spine Instability Questionnaire?
this is not ‘diagnostic’ – rather a predictor of who will benefit from MCE
What are 9 subjective findings when we assess for motor control impairments?
- History of symptoms related to repetitive loading – cricket, rowing, tennis
- Subacute to persistent symptoms (not acute LBP)
- Intermittent/recurrent symptom history
- Feelings or sensation of giving way
- Pain when not getting up in the right way (ie sitting from lying)
- Catching pain on movement
- Episodes of back ‘spasms’
- Pain increased with mild, unexpected or quick movements All people with acute LBP have pain with mild mvt but chronic LBP should not
- Significantly better with support – brace or chair
Why are reccurrent symptoms important to know?
Might be beneficial for motor control training
What are 2 physical findings when we assess for motor control impairments?
- Aberrant movements observed on AROM
- Treatment direction tests – modifying symptoms where possible
What are 2 activities that will be done when assessing motor control?
- Assessing symptom response in changing posture
- Assessing symptom response in changing a technique
These are still considered somewhat a motor control assessment as they assess awareness, strength and endurance.
What are 2 major considerations for assessing motor control in LBP?
- Studies which demonstrate effectiveness of motor control exercises are intensive and for several weeks – if patient is unlikely to be adherent and we cannot monitor them to progress exercise – consider what exercise they can do/will do. Therefore patient preferences are priority.
- Motor control retraining/stabilisation exercise will not change pain, function or behaviour in the immediate/short term – so for the patient with higher levels of pain/acute pain and difficulty moving – this could be poor prioritising of time SUMMARY How to decide if should do motor control training? • Do they adherence to exercise? ○ Don’t want to start a program with someone who is adherent to exercise • Acute LBP ○ Not a pain relieving strategy Only prescribe motor control training to motivated and adherent to exercises
How to very quickly decide if should do motor control training?
- Do they adherence to exercise?
- Don’t want to start a program with someone who is adherent to exercise
- Acute LBP
- Not a pain relieving strategy
- Only prescribe motor control training to motivated and adherent to exercises
What is a flexion control impairment?
they may go into flexion early and easily on movements – may have history of pain with flexion based activities – we want to assess whether they can control a movement without going into lumbar flexion
What is a question that must be asked to confirm a possible flexion control impairment?
Do they have difficulty maintaining a neutral spine without going into flexion.
What happens in a flexion control impairment?
Pain with flexion-related tasks or loading in flexion
What does the have difficulty or pain with?
Often have a history of pain with extension based activities (gymnast, tennis serve, running)
They go into increased lumbopelvic extension on movements or don’t reverse their lumbar lordosis
We might want to assess whether they can control a movement without going into extension
What is a question that must be asked to confirm a possible extension control impairment?
Do they have difficulty maintaining a neutral spine without going into extension?.
What happens in an extension control impairment?
Go into lumbar lordosis or anterior pelvic tilt
What are 6 types of test for muscle systems?
- OBSERVATION – muscle bulk, pelvic tilt, buttocks
- OBSERVATION OF FUNCTIONAL TASK – squat, deadlift, lifting, any other activity patient has difficulty or pain with – ability to keep neutral spine but not hypervigilant.
- AROM – presence of aberrant movement patterns – ie hingeing, can they relax ES on flexion, restriction in side flexion – consider QL length, aberrant movement patterns
- MOTOR CONTROL TESTS
- MUSCLE STRENGTH TESTS where appropriate – consider glute max, glute med, iliacus, lumbar extensors, global muscle strength – plank hold – ability to keep neutral spine.
- MUSCLE LENGTH TESTS where appropriate– piriformis, hamstring, hip flexor, TFL
When would I include motor control assessment within the physical exam?
- Research has indicated WHICH patients are likely to benefit from motor control retraining versus other/general exercise for LBP
- We need to decide whether it is a priority for use of time and likelihood of enhancing immediate outcomes
- Consider value of treatment direction tests – can we modify patients symptoms
- On a functional task that they report pain with
Don’t assess motor control unless they are a part of the subgroup that will benefit from it
