Lumbar Motor Control Training

 During the 1990s and 2000s a large number of papers have been published on lumbar motor control training, led by researchers from the University of Queensland. Practitioners across the world now recognise that local (commonly called “core”) muscles such as transversus abdominis, lumbar multifidus and the pelvic floor need assessment and consideration for inclusion in an integrated treatment program. A recent systematic review evaluating the effectiveness of motor control exercise targeting these muscles concluded:

“The pooled results favored motor control exercise (MCE) compared with general exercise with regard to pain in the short and intermediate term and with regard to disability during all time periods. MCE was also superior to spinal manual therapy with regard to disability during all time periods but not with regard to pain. Compared with minimal intervention, MCE was superior with regard to both pain and disability during all time periods.”

Bystrom et al 2013[1] 

Figure 1: Transversus abdominis (from en.wikipedia.org)

Figure 2: Lumbar multifidus on the left of the spine (from en.wikipedia.org)

Justification for lumbar motor control training

Specific motor control training as part of the treatment protocol was based on the principles developed by Richardson and colleagues.[2]Extensive research has been published on the importance of normal motor control in the lumbar spine including but not limited to:
• An anatomical and biomechanical suitability of the core muscles for providing stability to structures in the lumbar spine[3][4] 
• Feedforward mechanisms in people without a LBD resulting in “pre-setting” of the core muscles in anticipation of postural perturbation[5][6] 
• Contraction of core muscles independent of direction of trunk forces and movements[7][8] 
• Maladaptive differences between people with and without LBD in terms of altered feedforward mechanisms,[9][10] reduced core muscle cross sectional size,[11][12] increased global muscle activity in certain subgroups[13] and altered cortical representation of motor patterns[14]

This substantial literature has led to the hypothesis that correcting maladaptive motor control is an important component in the rehabilitation of LBD and prevention of recurrence.[4][2] This hypothesis is strengthened based on clinical data showing a reversal of the maladaptive changes observed in people with LBD[11][15] which is not achieved by less specific exercise such as abdominal bracing or general exercise.[16][17] In addition, RCTs have shown significant improvement for pain and activity in participants receiving specific motor control training compared to usual care[18][19] with larger effects demonstrable when homogenous subgroups are recruited.[20] Recent controversy around specific motor control training[21][22] has been refuted based on an insufficient consideration of this expansive literature as a whole.[20]

There is clear and extensive mechanistic and randomised controlled trial based data supporting the rationale for precise motor control training for LBD.

  1. ↑ Bystrom MG, Rasmussen-Barr E, Grooten WJ. Motor control exercises reduces pain and disability in chronic and recurrent low back pain: a meta-analysis. Spine (Phila Pa 1976). 2013; 38(6): E350-8
  2. ↑ 2.0 2.1 Richardson C, Jull G, Hodges P. Therapeutic exercise for lumbopelvic stabilisation: a motor control approach for the treatment and prevention of low back pain. Edinburgh: Churchill Livingstone; 2004 Cite error: Invalid <ref> tag; name "Richardson et al 2004" defined multiple times with different content
  3. ↑ Barker P, Briggs, CA, Bogeski, G. Tensile transmission across the lumbar fasciae in embalmed cadavers: effects of tension to various muscular attachments. Spine. 2004; 29: 129-38
  4. ↑ 4.0 4.1 Hodges P, Kaigle, HA, Holm, S, Ekström, L, Cresswell, A, Hansson, T, Thorstensson, A. . Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: in vivo porcine studies. Spine. 2003; 28(23): 2594-601 Cite error: Invalid <ref> tag; name "Hodges et al 2003" defined multiple times with different content
  5. ↑ Cresswell A, Oddsson, L, Thorstensson, A. The influence of sudden perturbations on trunk muscle activity and intra-abdominal pressure while standing. Exp Brain res. 1994; 98: 336-41
  6. ↑ Hodges P, Richardson C. Contraction of the abdominal muscles associated with movement of the lower limb. Physical Therapy. 1997; 77(2): 132-44
  7. ↑ Cresswell A, Grundstrom H, Thorstensson A. Observations on intra-abdominal pressure and patterns of abdominal intra-muscular activity in man. Acta Physiology Scandinavia. 1992
  8. ↑ Hodges P, Cresswell, A & Thorstensson, A. Preparatory trunk motion accompanies rapid upper limb movement. Exp Brain Res. 1999; 124: 69-79
  9. ↑ Hodges P, Richardson C. Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine. 1996; 21: 2640-50
  10. ↑ MacDonald D, Moseley G, Hodges P. Why do some patients keep hurting their back? Evidence of ongoing back muscle dysfunction during remission from recurrent back pain. Pain. 2009; 142(3): 183-8
  11. ↑ 11.0 11.1 Hides J, Lambrecht G, Richardson C, Stanton W, Armbrecht G, Pruett C, et al. The effects of rehabilitation on the muscles of the trunk following prolonged bed rest. European Spine Journal. 2010 Cite error: Invalid <ref> tag; name "Hides et al 2010" defined multiple times with different content
  12. ↑ Dickx N, Cagnie B, Parlevliet T, Lavens A, Danneels L. The effect of unilateral muscle pain on recruitment of the lumbar multifidus during automatic contraction. An experimental pain study. Manual Therapy. 2010; 15(4): 364-9
  13. ↑ Dankaerts W, O'Sullivan P, Burnett A, Straker L. Altered patterns of superficial trunk muscle activation during sitting in nonspecific chronic low back pain patients: importance of subclassification. Spine. 2006; 31(17): 2017-23
  14. ↑ Tsao H, Galea M, Hodges P. Reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain. Brain. 2008; 131(8): 2161-71
  15. ↑ Vasseljen O, Fladmark A. Abdominal muscle contraction thickness and function after specific and general exercises: a randomized controlled trial in chronic low back pain patients. Man Ther. 2010; 15(5): 482-9
  16. ↑ Ferreira P, Ferreira M, Maher C, Refshauge K, Herbert R, Hodges P. Changes in recruitment of transversus abdominis correlate with disability in people with chronic low back pain. British Journal of Sports Medicine. 2009; 44(16): 1166-72
  17. ↑ Hall L, Tsao H, MacDonald D, Coppieters M, Hodges P. Immediate effects of co-contraction training on motor control of the trunk muscles in people with recurrent low back pain. Journal of electromyography and kinesiology: official journal of the International Society of Electrophysiological Kinesiology. 2009; 19(5): 763
  18. ↑ Ferreira P, Ferreira M, Maher C, Herbert R, Refshauge K. Specific stabilisation exercise for spinal and pelvic pain: a systematic review. Australian Journal of Physiotherapy. 2006; 52(2): 79-88
  19. ↑ Macedo L, Maher C, Latimer J, McAuley J. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Physical Therapy. 2009; 89(1): 9-25
  20. ↑ 20.0 20.1 Hodges P. Transversus abdominis: a different view of the elephant. British Journal of Sports Medicine. 2008; 42(12): 941-4
  21. ↑ Allison G, Morris S. Transversus abdominis and core stability: has the pendulum swung? British Journal of Sports Medicine. 2008; 42(11): 630-1
  22. ↑ McGill SM. Low back disorders: Evidence-based prevention and rehabilitation 2nd ed. Illinois: Human Kinetics Publishers; 2008
Retrieved from "https://www.physio-pedia.com/index.php?title=Lumbar_Motor_Control_Training&oldid=77677"