If you
rehabilitate movement you should know this
Background
It
became obvious in the clinic in the 90's that some people did not respond to
specific motor control exercise. This was even after our best screening for non
mechanical pain and behavioral factors. On courses we just told people it was
just "proprioception". So in the clinic I spent quite a bit of extra
time with people, used various types of sensory motor function, treated them
for free for a long time. No luck. They just couldn't seem to get it regardless
of what I did.
After
some interesting findings with patients I asked my sister (Masters in special
education) if children with learning
difficulties have sensory or motor problems. This led me to a whole other world
of reading. It was obvious that the rehab world had missed something very
important. These problems and movement patterns had been around a very long
time and doing some basic proprioception was not going to change it. This
coincided with the findings from The
Movement Project.
The Learning Project was needed to understand the
epidemiology of this problem, the causes, solutions and associations to other
sub-classifications.
Epidemiology
Approximately
20% of people with chronic low back pain, 10% of acute low back pain and 30% of
whiplash associated disorders (WAD) cannot learn these exercises. The WAD group
may be due to the specific injury and pain regions which may more adversely
influence the sensory motor system.
Screening
The
Motor Control Abilities Questionnaire (MCAQ) was developed to screen people for
their ability to learn. It is a very accurate tool and works well clinically. The
tool has been used in two clinical trials and several prospective cohort
studies. This early research is very promising (See below for the research on
the 10% of false negatives).
Sub-classification & Causes
Relevant
Neurological Factors include: neurocognitive function, sensory motor deficits,
and neurological soft signs including primitive reflexes.
There
are numerous causes of these Neurological Factors. These include:
- Genetics
- Congenital disorders
- Obstetric and neurodevelopmental problems
- Social factors, enrichment
- Childhood diseases
- Multiple surgeries with anesthesia
- Side effects of medication
- Aging
- Neuro-Immune-Sympathetic-Endocrine dys-regulation (NISE Syndrome)
Treatment
When
looking at treatments, I first looked at interventions for children with
learning difficulties. These included primitive reflex inhibition and sensory
motor rehab. These were modified and made much more specific for adults with
pain. I then added postural reflexes and had to develop others. There are other
strategies to help neurocognitive or sensory motor function. The underlying
mechanism needs to be addressed.
Associations
We
have found associations with higher score on the MCAQ with behavioral conditions,
non mechanical pain and NISE syndrome related conditions. These associations
(odds ratios) are variable depending on the MCAQ scores. It is clear that not all people who score above our cut
point have non mechanical pain or behavioral conditions.
"Learning Deniers"
Specific
motor control exercise are different from other exercises. They have greater
sensory motor and neurocognitive requirements. We've assessed by teaching
different exercises to special education teachers and having them rate the
neurodevelopmental learning constructs.
One
of the biggest problems clinicians have when implementing specific motor
control exercises with patients is teaching them how to do it with the
precision that is required. This was very clear from a survey I did.
Some
of the "heads" of the schools of thought, researchers and clinicians
are learning "deniers". If your patient population is university
based or have higher education with private insurance, you fundamentally have a
different population. As well, if you do not follow up with people who don't
return, you don't really have the
ability to comment on this properly.
Many
countries have a physiotherapy culture that has a "nickname" for
people who have trouble taking instructions or learning to change their
coordination. No one seems to have a solution for these people. We do.
There
are several reasons why patients do not respond to the therapy. The inability
to learn is an important one which we can now screen for and intervene for.
Summary
Specific
motor control exercises are effective interventions when appropriate
sub-classification is used. We have to accept that not everyone can learn
specific motor control exercise. The MCAQ is an accurate easy to use screening
tool to predict if people can learn these exercises. When people can't learn,
we can intervene using primitive reflex inhibition, specific sensory motor
function and postural responses. After years of using the MCAQ I decided to
look at the 10% of people who were the false negatives (e.g. the questionnaire
predicted they could learn, but they could not). This led to The Body Image Project. This allowed me
to develop the concept of midline as a sensory system and body image pain.
Sean GT Gibbons BSc (Hons) PT, MSc Ergonomics, PhD (c),
MCPA
References
Lehtola V, Luomajoki H, Leinonen V, Gibbons SGT, Airaksinen
O 2016 Sub-classification based specific movement control exercises are
superior to general exercise in sub-acute low back pain when both are combined
with manual therapy: A randomized controlled trial. BMC Musculoskeletal
Disorders . 17:135. DOI: 10.1186/s12891-016-0986-y
Gibbons
SGT 2016 Is neurocognitive function associated with the ability to perform
motor imagery in adults with musculoskeletal pain? A retrospective case control
study. Proceedings of: “Cognitive Vitality” The
CAPM&R 64th Annual Scientific Meeting. May
25-29, London, Ontario. Journal of Rehabilitation
Medicine
Gibbons
SGT 2016 Are a battery of obstetric and neurodevelopmental variables are
associated with a subgroup of fibromyalgia and un-classified pain patients. A
retrospective case control study. Proceedings of: “Cognitive Vitality” The CAPM&R 64th Annual Scientific
Meeting. May 25-29, London, Ontario. Journal of Rehabilitation
Medicine
Gibbons
SGT 2016 Preliminary development of items to identify a neuro-immune-autonomic-endocrine
involvement in complex pain presentations. Proceedings of "Expanding
Horizons": The 11th International Conference of IFOMT. July
4-8; Glasgow, Scotland
Gibbons SGT 2016 Should central pain be
sub-classified? A hypothesis of Musculoskeletal Body Image Pain - initial
insights into diagnostic criteria. 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 2014 Sub-classification, diagnosis and rehabilitation of musculoskeletal body
image disorders. 62nd Annual Scientific Meeting of the Canadian Association of
Physical Medicine and Rehabilitation. St. John's, June 18-21
Gibbons SGT 2012 Facilitating neuroplasticity
for pain, movement and function.
Manitoba Physiotherapy Association. April 13; Winnipeg, Manitoba
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 2010 Primitive reflex inhibition
and sensory motor training improves cognitive learning function and symptoms in
chronic disabling low back pain: A case series.
Proceedings of: The 7th
Interdisciplinary World Congress on Low Back Pain. November 9-12; Los Angeles,
USA
Gibbons SGT 2010 The development,
initial reliability and construct validity of the motor control abilities
questionnaire. Proceedings of: The 7th Interdisciplinary World
Congress on Low Back Pain. November 9-12; Los Angeles, US
Gibbons SGT 2010 The relevance of
neurocognitive deficits in treating musculoskeletal pain. Proceedings of: ECT 2010 - “Neurological concepts
and impact of manual therapy on pain”, Sept 23-25; Antwerp, Belgium
Gibbons SGT 2010 Benefits and
limitations with specific motor control rehabilitation Proceedings of: ECT 2010 - “Neurological concepts
and impact of manual therapy on pain”, Sept 23-25; Antwerp, Belgium
Gibbons SGT 2010 What does chronic pain have in
common with learning difficulties?
Proceedings of: Neurodynamics & The Neuromatrix Conference. April
15-17; Nottingham, England
Gibbons SGT 2010 Influence of cognitive
learning factors on psychosocial factors and central sensitization. Proceedings
of: Neurodynamics & The Neuromatrix Conference. April 15-17; Nottingham,
England
Gibbons SGT 2009 Implications of cognitive
learning function for outcome prediction, performance and rehabilitation. The
Second International Congress on Musculosqueletal and Sport Rehab. May 13-16;
Belo Horizonte, Brazil
Gibbons SGT 2008 The role of proprioception
& sensory motor function in rehabilitation, cognitive function &
outcome prediction. The 7th National Symposium of the Kuwaiti
Physical Therapy Association. November 12-13; Kuwait City, Kuwait
Gibbons SGT 2008 Retraining of asymmetry
in recruitment of transversus abdominis. Orthopaedic Division Review. March/April: 29-34
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