Is one screening tool enough to identify the diverse spectrum of behavioral factors that may influence a poor outcome in musculoskeletal pain?

Reference as:
Gibbons SGT (2019) Is one screening tool enough to identify the diverse spectrum of behavioral factors that may influence a poor outcome in musculoskeletal pain? Proceedings of: The 10th Interdisciplinary World Congress on Low Back Pain. October 28-31, 2019; Antwerp, Brussels

General Comment: A battery of ultra brief screens may be a way forward for screening the diverse array of behavioral presentations that present in chronic musculoskeletal pain. Current screens have limited diagnostic accuracy. This project was a feasibility study.

Introduction
Behavioral factors are known to predict a poor outcome from acute low back pain (LBP) and are associated with chronic LBP. The psychiatric and pain literature note many behavioral conditions that are associated with chronic pain. There are behavioral conditions that are not commonly recommended in screening since they are often co-morbid with other conditions that are screened. This screening approach has potential problems. First, the screening of only one behavioral condition will lower the accuracy of the screening since other relevant conditions may be missed. Second, it is not well understood how outcome is affected if multiple behavioral conditions are present. Third, the treatment for one behavioral condition is different from combinations of behavioral conditions.

Purpose/Aim
The purpose of this paper was to identify the percentage of patents that score above the cut off point on a battery of behavioral screening tools.

Materials and Methods
A clinical audit was performed on 485 patient charts: 223 LBP (85 acute/138 chronic); 118 whiplash associated disorders (WAD) (37 acute/ 81 chronic); 63 neck pain (11 acute/ 52 chronic); 81 peripheral regions. The following behavioral factors were assessed using a battery of previously validated short questionnaires with cut off points. Category 1 included: anxiety (2 items); kinesiophobia (1 item); catastrophication / recovery expectation (1 item); ); stress (2 items); post traumatic stress disorder (4 items). Category 2 included: depression (2 items); hopelessness (1 item). Category 3 included: self esteem (1 item); body appreciation (2 items). Category 4 included personality disorders (8 items). Category 5 included social factors (2 items). A category was considered positive if any one score for any condition was recorded above the suggested cut off score. Descriptive statistics were used. Standard practice was to assess outcome with a 7 point Global Rating of Change scale; Numerical Rating Scale for pain, function with the Patient Specific Functional Scale and a disability questionnaire related to the body region: Roland Morris Disability Questionnaire; Neck Disability Index.

Results
The questionnaire took under 10 minutes to complete. Missing values were under 2%. A poor outcome was considered not improving beyond the minimal clinically important change (MCIC) on any domain using evidence based interventions. A poor outcome was found in 68% (1 category positive; n=12); 82% (2 categories positive; n=17); 92% (3 categories positive; n=26); 100% (4 categories positive; n=23).

Conclusion(s)
This clinical audit suggests that a variety of behavioral factors present with musculoskeletal pain. As well, scores above the recommended cut off point suggested cut off values for multiple categories of behavioral factors may be more predictive of outcome than 1. There is a clear need to understand how the interaction of psychiatric conditions in different categories influences the response to different therapies. Using multiple short questionnaires appears to be feasible. Further research is needed to test the reliability of the items used as a whole and to control for subejct's co-treatments and exposures in a larger sample.

Keywords
Low back pain, whiplash associated disorders, psychosocial factors, outcome, screening, Sub-classification

Transversus and Multifidus rehab does help a subgroup of low back pain. The case is not closed!

This type of rehabilitation is heavily criticized. There are numerous reasons for this such as the non functional nature of the exercises and the results of results of systemic reviews. 

I have over a dozen systematic reviews and or meta-analysis in my personal library. In general the results say that these specific motor control stability exercises (SMCSE) are better than no / minimal intervention, but not better than other active interventions. 

I have done one systematic review as part of the course work for my PhD (see reference below) and I have updated it for my thesis. 

 https://www.researchgate.net/publication/339362910_Specific_Motor_Control_Exercise_for_Lumbo-pelvic_Pain_of_Articular_Origin_A_Systematic_Review

First, there is evidence  to support these exercises when a subgroup of non specific low back is used (when there is evidence of articular related low back pain). I guess this could be argued that it isn't actually "non-specific low back pain", but that's a separate discussion. Only one of all these systematic reviews did actually bother to separately look at "more specific" low back pain. 

Second, there are actually conflicting results in these reviews. This is when short term outcomes are compared, and when meta-analyses are considered.

Thirdly, there is considerable difficulty in analyzing these studies and putting them into groups (e.g. specific exercise on its own or + other intervention (active and or passive, and or education). Comparison groups are quite variable (active intervention, passive intervention, education, combinations of  etc). This highlights the problem of the lack of a standard therapy for research use.

The "pundits" will state that the supporters of SMCSE will cry about "the exercises weren't done right". Is this an issue? Well, when I lectured to a group of MSc students on the UK (who were all meant to be very experienced), only one actually knew how to palpate a contraction of an exercise biased for transversus abdominus. This is actually worse than normal when I give lectures. In general, between 40% - 50% of clinicians do not know how to do this. Some of these people are physiotherapy specialists and a few even teach continuing education courses. There are a lot of professional issues here of course. As echoed in the literature, it takes a high degree of skill by the therapist to know how to properly implement SMCSE.

I have no idea of course how this equates to the exercises used in clinical trials. Certainly the instructions used in many seem suspect. This highlights the need for standardized instructions and reporting in exercises used in clinical trials. 

There is also a considerable body of evidence to support the rationale for the use of SMCSE which tends to be forgotten and misrepresented. Too often, some of the early research is quoted and misrepresented.

Let's not forget, there are of course numerous agendas, biases and other issues related to this topic. So no, the case is not closed. In fact, with the current evidence SMCSE are not guilty and in fact play a role in the rehabilitation of articular related low back pain. 

We know who to use the exercises with and we have preliminary evidence to predict who will respond.

Rule in:

• Articular related low back pain
• Good motor skill learning (assessed with the Motor Control Abilities Questionnaire)https://www.researchgate.net/publication/339363667_O27_The_development_initial_reliability_and_construct_validity_of_the_motor_control_abilities_questionnaire?_

Rule out:

• Behavioral Factors
• Non mechanical pain
• Chronic Low Grade Systemic Inflammation https://www.researchgate.net/publication/339127713_Are_co-morbid_medical_symptoms_associated_with_poor_response_to_sub-classification_based_management_of_chronic_low_back_pain_A_retrospective_case-control_study

So we need a clinical trial with articular related low back pain due to similar causes and compared to an exercise intervention that does not cognitively alter or control movement.

If You Rehabilitate Movement You Should Know About Primitive Reflexes

Primitive Reflexes influencing Motor Control & Motor Skill Learning. Come Learn! 

It's so logical why isn't it part of mainstream rehab?

If someone isn't moving well, rehab the strategies in which they learned how to originally move.

Primitive reflexes are essentially what guides infantile movements. They are very easy to rehab. Just low effort resistance in the correct patterns of the reflex.

What do we know about primitive reflexes for musculoskeletal pain?

• Having PR interferes with normal motor control and coordination
• Having PR interferes with learning motor control exercise or normal movement
• PR inhibition helps normal motor control and movement
• PR inhibition helps postural stability and balance
• PR inhibition helps neurocognitive function
• PR inhibition helps body image
• PR are stimulated by a sensory stimulus. Most are vestibular related and some are tactile

This course is suitable for orthopaedic, paediatric, neurological, pelvic floor and vestibular physiotherapists

Course Description

Some questions beg answers

How do you rehab someone with poor coordination?

Why does the brain move the body in a harmful way?

Why do some people never regain full ROM?

This course will answer these questions & more!

Primitive reflexes (PR) are brain stem-mediated, complex automatic movement patterns that commence in utero.  If PR persist beyond their average lifespan they may begin to interfere with normal movement, motor control and brain development. They present in a variety of conditions relevant to you such as MSK pain, concussion, atypical handedness / birth, early-late walking.

The presence of PR will influence motor control and can interfere with normal rehabilitation. 

During this two day course we will cover the assessment and rehabilitation of primitive reflexes in detail.  Strategies for treatment in the clinic and home exercise will be discussed. You will be able to immediately improve movement and motor control in your patients.

Specific examples of what PR can be used to improve highly common clinical problems including:

• Grasp reflex for shoulder upper limb coordination and glenohumeral medial rotation ROM

• Babinski and Foot Tendon Guard for lower limb & gait coordination, and dorsiflexion ROM

• Asymmetrical Tonic Neck & Abdominal Reflexes for abdominal hollowing, & trunk coordination

• Landau for hamstrings and trunk tone

The traditional view that PR are inhibited by normal movement is limited. The cognitive replication, rather than reproduction of PR inhibits them. PR are highly effective at rehabilitating normal movement, and neurocognitive function. 

Course Objectives:

The participant will be equipped to:

• Use primitive reflexes to rehab patients with very poor coordination & motor skill  learning

• Understand the role of primitive reflexes in pain, cognitive function and motor control.

•  Assess and rehabilitate primitive reflexes in children and adults

• Implement a home exercise program for primitive reflex inhibition

• Use primitive reflex inhibition strategies to improve movement & motor control 

Testimonial

"This course is a game changer. Sean continues to push physiotherapists to think beyond the standard orthopedic model, incorporating neurological, neuro-developmental, functional medicine and original research into a model that answers so many questions regarding each patient's unique pain experience. His midline and musculoskeletal body image work is revolutionary"

"Finally, I have a way to treat motor morons"

Chris Barber Physiotherapist

"Finally, I have a way to treat motor morons"

"Movement changes so quickly - and maintains"

Chris Barber Physiotherapist

What will you get from this course that you may not already have?

A rehab option for "Motor Morons". Neurodevelopmental rehab works for these patients

Improve Muscle Tone & Motor Control

Learn how to use PR to reduce tone and muscle tightness, improve movement and coordination.

Stop Wasting Time: quickly rule out the people who have poor motor skill learning

Understand the role of Primitive Reflexes in pain, cognitive function and motor control.  This is also important for neurological rehab.

Concussion

Find out how to help rehab concussion with primitive reflexes

Pediatrics, Neuro, Vestibular, Pelvic Floor Physios

The same primitive reflex inhibition techniques can be used very effectively with these groups 

Regardless of how much knowledge you have you will benefit from knowing:

• Screening who has poor motor skill learning

• Strategies to rehab motor morons

• Which Postural and primitive reflexes to immediately change movement patterns and performance on  specific motor control exercise

Want to Learn?

Ottawa, Canada: March 6-8, 2020: Primitive Reflex & Motor Skill Learning

Barcelona, Spain: March 20-22, 2020: Primitive Reflex & Motor Skill Learning

Toronto, Canada: May 2-3: Body Image, Motor Skill Learning & Primitive Reflexes for Pelvic Health 

Warsaw, Poland: May 8-10: Primitive Reflexes

Warsaw, Poland: May 11-13: Body Image, Motor Skill Learning & Advanced Primitive Reflexes

Harrogate, UK: May 16-17: Body Image, Motor Skill Learning & Advanced Primitive Reflexes

Montreal, Canada: June 5-7: Body Image, Motor Skill Learning & Advanced Primitive Reflexes for Pelvic Health 

Milan, Italy: June 19-21: Advanced Concussion & Body Image

For more information email: stabilityphysio@gmail.com

visit: www.smarterehab.org

Primitive Reflex Related Posts

https://smarterehab.blogspot.com/2020/02/lets-be-clear-neurological-soft-signs.html

https://smarterehab.blogspot.com/2019/12/wy-should-all-physiotherapists-be.html

https://smarterehab.blogspot.com/2016/11/why-does-replicating-primitive-reflex.html

https://smarterehab.blogspot.com/2019/09/if-you-can-do-muscle-energy-technique.html

https://smarterehab.blogspot.com/2016/11/symmetrical-tonic-neck-reflex-new-look.html

https://smarterehab.blogspot.com/2016/11/is-functional-hallux-limitis-sign-of.html

https://smarterehab.blogspot.com/2016/11/is-idiopathic-toe-walking-caused-by.html

Testimonials

“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 courses have 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 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 by identifying the underlying movement dysfunction and easily explaining it’s cause. Thank you 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, guidelines that are untouched by other institutions. Places are limited. Jean-Michel Cormier, Physiotherapist Max Health Institute, Shediac, NB, Canada
The courses that I have taken with Sean have completely changed my pelvic floor practice and the way I practice as a physical therapist! Sean's courses are a must in order to help a variety of clientele and especially those who do not respond to conventional treatments! He has researched and developed new techniques that are essential for pelvic floor therapists. Erica Lafontant, pht, B. Sc, M.Sc.A Rééducation périnéale et . Action Physio. Ville Mont-Royal, QC,

Sean Gibbons graduated from Manchester University in 1995. He has been rehabilitating movement patterns and chronic pain his whole career. 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: Neurological Factors, which are related to extremely poor movement and motor skill learning; Body Image & Body Image Pain; and Chronic Low Grade Systemic Inflammation which is the cause of most chronic disease. His current work aims to further validate the screening tools and understand the underlying causes of each subgroup. The importance of individual factors such as the therapeutic relationship and patient beliefs are also considered. 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 and lectures at Manchester Metropolitan University's Masters in Advanced Physiotherapy program.

Is Musculoskeletal Body Image Relevant for Pelvic Health? 7th Pelvic Health Symposium – Toronto, Canada

It is my pleasure to present at the 7th Pelvic Health Symposium in Toronto Canada on May 1, 2020.
Various categories of therapeutic exercises have a strong evidence base in pelvic floor rehabilitation, including motor control exercise.  Explicit motor skill learning principles are recommended to teach patients specific motor control exercise. This requires the participant to have adequate sensory motor function, working memory, attention and executive function. Motor Imagery is often used during the initial phase of motor skill learning, however some patient subgroups have deficits in motor imagery, sensory motor function and neurocognitive function.

This influences the ability of clients to learn the exercise and benefit from the therapy. Hence there is considerable variation in learning ability, which is likely involved in the time frame for rehabilitation and overall outcomes.

There is now a greater understanding of the virtual body in musculoskeletal dysfunction. One related topic is musculoskeletal body image. Body image is the way one’s body feels to its owner. This feeling includes, the shape, outline, alignment in space, weight, muscle tone and ownership. The feeling of one’s body is involved in producing an accurate image of their body to be used for motor skill learning.

This lecture will discuss our research on motor skill learning, body image and the implications for clinical practice.

At the end of this lecture, the learner will be able to:
·        Recognize clients with poor motor skill learning abilities
·        Reflect on motor skill learning ability in pelvic health clients
·        Identify patients with body image deficits
·        Consider rehabilitation options for clients with poor motor skill learning
For more information: https://pelvichealthsolutions.ca/event/7th-pelvic-health-symposium-may-2020/
There will be a post conference course on the topic: "Body Image, Motor skill Learning & Midline for Pelvic Health"

There will be a post conference course: Body Image, Motor Skill Learning Midline For Pelvic Health

Course Description:
Motor imagery is needed to perform specific motor control exercises.
How do you assess it?
What influences motor imagery?
How do you rehab someone with very poor coordination? Or who just doesn’t get it?
The brain needs to know what is happening in the body. It gets this information from sensory feedback which are used to form virtual body maps. When this information is deficient the brain will change behaviour to get this information. Pain and other symptoms can be produced as a result.
Normal healthy coordination and body image are learned during the neurodevelopmental process. This includes primitive reflexes and key postural reflexes such as rolling and crawling. Good motor skill learning requires a good body image and motor imagery skill.
Efficient muscle contractions and movements depend on the ability to focus on the body part with motor imagery. Imagery is impaired in many common presentations (e.g. ADHD, DCD, atypical handedness). This is quickly modifiable with body image rehab.
You will leave with a clear understanding of how to assess and treat poor motor skill learning (including Motor Morons!), musculoskeletal body image deficits along with the appropriate subjective history, physical examination and outcome measures to use. The course will cover in detail appropriate starting points, appropriate progressions and problem solving strategies.
Numerous primitive reflexes and postural reflexes have a specific influence on the pelvic floor, sacro-iliac joint, trunk and breathing.
You will be able to successfully treat many patients you could not previously rehab.
Course Objectives:
The participant will be able to:

• Identify patients with poor motor skill learning & Body Image deficits
• Assess and rehabilitate motor imagery and body image deficits
• Be able to assess & rehab primitive & postural reflexes that influence pelvic floor rehab
• Develop a rehabilitation program for patients with poor motor skill learning, musculoskeletal body image disorders with appropriate starting points and progressions

What Will You Get From This Course That You May Not Already Have?

• Body Image
• We will show you how to assess for body Image disorders and rehabilitation strategies which can be applied to a wide range of other conditions and clinical presentations.
• Midline & Vestibular Patterning
• We have researched and developed the concept of midline as sensory system. Find out what it is and how to assess & rehab it.
• Motor Skill Learning – Improve Motor Control
• Not everyone can learn specific motor control exercises. We will show you how to quickly screen and how you can rehab this with specific sensory motor and neurodevelopmental rehab.
• Postural & Primitive Reflexes
• Immediately change movement patterns, help people who have poor motor skill learning

 Regardless of how much knowledge you have you will benefit from knowing:

• Rehab of musculoskeletal body image & midline
• Primitive reflex inhibition & postural reflexes
• Screening who can learn specific motor control exercise and correct sub-classification

Audience: Open to all healthcare professionals. No prerequisites required.
Hours:
Saturday: 8:30am-4:30pm / Sunday: 8:30am-4:30pm
Registration begins on the first day 15 minutes prior to the start time.
For more information: https://pelvichealthsolutions.ca/event/body-image-motor-skill-learning-midline-for-pelvic-health-may-2020/

Body Image Drawing for Pelvic Health

There are numerous motor, sensory, psychological, immune, cardiometabolic, and endocrine deficits that may occur in various pelvic health complaints. Other chronic musculoskeletal pain conditions have similar deficits. One are that is becoming more popular in musculoskeletal pain is body image. Moseley 2008 did a study on body image drawing in chronic low back pain. We have been clinically using this since that time and in 2011 did a reliability study on using a full body diagram to use the concept on all body areas. At tat time we did not consider pelvic health. We are currently researching a version for Pelvic Health patients.

Most evidence based rehab strategies involve using motor imagery of the pelvic floor and related regions. Not everyone can perform motor imagery very well and some cannot at all. Body Image Drawing is one way to assess this.

On our courses, we show you show how to assess body image, why it is relevant and how to rehab it.

Related post:
https://smarterehab.blogspot.com/2020/02/what-is-musculoskeletal-body-image-why.html

Want to Learn?

Ottawa, Canada: March 6-8, 2020: Primitive Reflex & Motor Skill Learning

Barcelona, Spain: March 20-22, 2020: Primitive Reflex & Motor Skill Learning

Toronto, Canada: May 2-3: Body Image, Motor Skill Learning & Primitive Reflexes for Pelvic Health 

Warsaw, Poland: May 8-10: Primitive Reflexes

Warsaw, Poland: May 11-13: Body Image, Motor Skill Learning & Advanced Primitive Reflexes

Harrogate, UK: May 16-17: Body Image, Motor Skill Learning & Advanced Primitive Reflexes

Montreal, Canada: June 5-7: Body Image, Motor Skill Learning & Advanced Primitive Reflexes for Pelvic Health 

Milan, Italy: June 19-21: Advanced Concussion & Body Image

For more information email: stabilityphysio@gmail.com

visit: www.smarterehab.org

Testimonials
“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 courses have 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 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 by identifying the underlying movement dysfunction and easily explaining it’s cause. Thank you 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, guidelines that are untouched by other institutions. Places are limited.  
Jean-Michel Cormier, Physiotherapist Max Health Institute, Shediac, NB, Canada

The courses that I have taken with Sean have completely changed my pelvic floor practice and the way I practice as a physical therapist! Sean's courses are a must in order to help a variety of clientele and especially those who do not respond to conventional treatments! He has researched and developed new techniques that are essential for pelvic floor therapists.  
Erica Lafontant, pht, B. Sc, M.Sc.A Rééducation périnéale et . Action Physio. Ville Mont-Royal, QC,

Sean Gibbons graduated from Manchester University in 1995. He has been rehabilitating movement patterns and chronic pain his whole career. 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: Neurological Factors, which are related to extremely poor movement and motor skill learning; Body Image & Body Image Pain; and Chronic Low Grade Systemic Inflammation which is the cause of most chronic disease. His current work aims to further validate the screening tools and understand the underlying causes of each subgroup. The importance of individual factors such as the therapeutic relationship and patient beliefs are also considered. 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 and lectures at Manchester Metropolitan University's Masters in Advanced Physiotherapy program.