Lumbar Flexion related pain in a rower: Brief Case over view of Sub-classification Functional Mechanism Based Rehab

Direct referral via email: I have started rowing and have developed low back pain now that training is more intense. It is starting to get worse. Can you see me?

Intake questionnaires Prior to first visit

Neuro-immune- Sympathetic-Endocrine Screen (NISE) (predicts systemic / neurogenic inflammation): 1/18 (Negative)

Behavioral Screening: Negative

Central Sensitization Screen: Negative

Motor Control Abilities Questionnaire (MCAQ) (predicts ability to learn specific motor control exercise): Negative (18)

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

Subjective History overview:

A 39 year old male engineer started rowing for a summer competition 12 weeks ago. 4 weeks ago, training was increased to twice daily. Low back pain (central) started three weeks ago and gets worse with training. It is not getting better and seems to be getting worse. It has started being aggravated by sitting at work, however there is an up-down desk in place and standing reduces the pain. There is no referral of symptoms. The pain was intermittent and is now constant (2/10) and gets worse with rowing (6/10) and sitting (3-4/10). Massage therapy did not help and "core training" with a personal trainer "specialist kinesiologist" did not help. Relevant past medical history: right hamstring strain 2006 with a full functional recovery and no recurrences.

Given he is an engineer (known relationship between autism spectrum disorders and false negatives on the MCAQ) I explored his birth history, development and related subjective history. This was despite his very low score on the MCAQ which would predict a very quick recovery.

Birth History: normal

Development: normal

Handedness: right. No mixed dominance

Sports: played a variety of sports and excelled at numerous sports

(So this would seem to be ruled out)

Clinical Reasoning thus far: The patient likely has lumbar flexion related symptoms which are aggravated due to repetitive flexion. It is likely that he has a hamstring restriction and a - hamstring - gluteus maximus muscle imbalance given his previous hamstring injury. Given he has a job that requires excessive sitting this may be contributing to an altered length - tension ratio in gluteus maximus. Neurodynamics needs to be considered as does lumbo-pelvic stability. The side of the oar may not be a priority day 1 since the pain is central, but needs to be considered. The local sources of pain would seem to be caused by the excessive flexion of the lumbar spine.

Physical Assessment Overview

Standing

Trunk flexion: initiates with hip flexion; lumbar flexion starts after 10 degrees and continues concurrently until 30 degrees. After this there is no further hip flexion and just lumbar flexion. He was able to cognitively control this movement (e.g. neutral lumbar spine with hip flexion) until 30 degrees without any eternal feedback. He was very confident and it was easy to do.

One leg standing: negative bilaterally

Prone over bed hip extension: negative for SIJ; positive bilaterally for lumbar extension with excessive hamstring tone and no increased palpable contraction of gluteus maximus

Trunk rotation control: normal bilaterally

Slump test: symptoms reproduced at end range and relieved with cervical extension or plantar flexion

Straight Leg Raise: Symptoms were not reproduced but the test was reactive with tightness at 50 degrees bilaterally and increased reactivity with femoral medial rotation, adduction or

Landau primitive reflex: positive

STNR primitive reflex: positive in extension and flexion

Pain provocation testing: quadratus lumborum trigger point bilaterally; L4 central PA

Articular testing above and below the kinetic chain: negative to influencing neurodynamics or movement pattern

Sub-classification to direct therapy:

Neurological Factors: normal (expect patient to learn specific motor control very quickly)

Pain Mechanism: nociceptive, segmental sensitization

Movement Pattern: Flexion related symptoms

Patho-anatomical: Articular / discogenic; dural; myofascial

Treatment Day 1

He was educated on his movement pattern and the difference between coordination type exercise and general strengthening. He was advised that he should immediately integrate this concept into his training. He commented that his coach had been trying to get him to keep his back more straight during the catch phase, however his symptoms were more pronounced at the release phase. He was able to immediately alter his kinetic chain so that his hips contributed more to trunk flexion during these phases. He was also able to cognitively create a neutral spine in the position mimicking these phases. I requested a video of his dry land training.

Exercises

Lumbar flexion control in standing and sitting (both were modified to become a neural mobilization exercise)

Landau primitive reflex

Lumbar spine specific neutral. This was immediately integrated into sitting and rowing.

Lumbar multifidus with normal breathing and encouraged a posterior and lateral basal pattern (this breathing pattern naturally lengthens quadratus lumborum)

Manual therapy to improve trunk extension and reduce neurodynamic responsiveness

Clinical interpretation:

This patient has scored under 20 on the MCAQ so it would be expected that he would be a very quick learner. The key to this patient's recovery is to quickly target the underlying mechanism and incorporate the rehab into function as soon as possible. The patient's movement pattern was limited by a restriction. This restriction appears to be neurodynamic and myofascial. The myofascial restriction is due to increased hamstring tone. This increase in hamstring tone is due to reduced gluteus maximus tone and the presence of primitive reflexes. It is also likely due to neurodynamic responsiveness. The movement pattern also changed with fatigue and it is likely that the tone changed with this as well.

Neurodynamic reactivity cause:

The patient has very good coordination and movement throughout other areas of his body (so a general stress of the movement system was less likely)

Scored low on the NISE Symptom Screen (so low risk for systemic or neurogenic inflammation)

No family history of type 2 diabetes, kidney disease, cardiovascular disease

Has a very healthy diet with lower than recommended carbohydrate intake

There is no history of trauma besides the previous hamstring injury which did have significant bruising.

The working hypothesis going forward was that the reactivity was due to the local segment irritation and the previous hamstring injury. Based on this, a very aggressive approach to neural mobilization will be adopted and to progress multifidus (for translation control) into function.

Fatigue is also an issue, however this will be addressed if needed.

Day 2 (one week later)

No pain during sitting at work with no need to stand

Minimal pain during training. The exercises are easily integrated into the training program.

The video showed that his movement pattern worsened as training continued (as he fatigued).

Exercises

Increase endurance of Landau

Advised to cognitively alter movement when fatigue starts. His coach was advised and would continually remind him. 

Prone over bed hip extension to improve gluteus maximus length tension function and the hamstring - gluteus maximus muscle imbalance.

Self neural mobilization (self slump in the rowing position, but a strategy to protect the lumbar spine as used).

Multifidus was to be performed in a variety of positions throughout the day and in the positions that aggravate the symptoms.

Lumbar rotation with a straight leg mobilization was done bilaterally

After discussion with the coach and the patient it was decided to increase the endurance of the exercises (e.g. Landau) and to increase aerobic endurance outside of rowing (e.g. running). He was also advised to regularly use the standing function of his up-down desk to avoid sitting with his gluteus maximus lengthened.  

Update (three days later)

The patient has no pain during training or sitting at work. However the coach has noted there are still issues with his movement pattern towards the end of training. He was advised to come back in a week or so for progression of his exercises and to continue to progress his endurance rehab.

Summary

Patient's who score low on the MCAQ recover very quickly with specific motor control rehabilitation. This patient fit that highly consistent pattern (100% thus far). His recovery was expedited by addressing the underlying mechanisms and involving his coach to help facilitate a quick integration into function.

The decision to use multifidus for translation control over psoas major or transversus was based on the ease of integrating into function and that the likely cause of the joint pain was the excessive lumbar flexion (hence the clinical priority was on controlling his movement pattern).

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: stabilityphysio@gmail.com

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.