David Johnson, Luke Armstrong, James Dooner, Joanne Johnson

Abstract

Study Design

We report on the outcomes from our prospective observational study into back pain symptom treatment using NeuroHAB defined Functional Movement Therapy. Although the findings are reflective of an association study not causation, the magnitude of post intervention out come data very likely represents high clinical and statistical significance.

Oswestry Disability Index scores (ODI) were collected prospectively over a two year period between 2016 and 2017. ODI scores were compared before and after implementation of a specifically defined, structured, progressive and reproducible movement proficiency training program referred to as NeuroHAB. The intervention has a distinctive primary focus on central nervous system derived motor pattern rehabilitation manifesting ultimately in skillful acquisition of clearly defined movement proficiency points of performance for activities of daily living.

Background

Global peer reviewed literature is increasingly acknowledging the failings of existing treatment paradigms to manage the growing economic and clinical burden of low back pain (LBP) symptoms. ^{5,6,10,11,17,18}

Low back pain is the leading cause of disability worldwide ^6,18 and its prevalence continues to increase despite a staggering explosion of treatment options, some considered conventional and many less so. ¹⁸ Invasive technology including interventional pain blocks and back pain surgery refinements are advancing exponentially in an attempt to effectively treat the often desperate needs of millions of back pain sufferers that ultimately resign to surgical intervention once physical, pharmaceutical and maladaptive behavioural measures fail. ⁴ Sadly many of these patients still continue to suffer unrelenting symptoms after surgery and remain as lost and bewildered as their medical or allied health therapists. ^6,10,24

Objectives

The first objective is to define desired optimal functional movement proficiency points of performance for activities of daily living in patients with chronic low back pain and then secondary to that transfer those defined kinematic skills to patients utilising a specific, reproducible movement proficiency based rehabilitation program that we have termed NeuroHAB. The ultimate objective is to demonstrate that the NeuroHAB methodology of increasing clearly defined skilful movement, results in improved clinical outcomes as assessed by pre and post intervention ODI scores in association with default expression of our NeuroHAB defined movement proficiency.

Methods

Desired movement points of performance were created by observing kinematic characteristics common to functional athletes and very young children and elderly individuals that maintained relatively high levels of functional capacity free of spine region pain.

ODI scores were collected on 142 chronic back pain patients before and after the eight week NeuroHAB intervention. Patients were entered into the NeuroHAB intervention program on the basis of greater than six months of persistent low back pain and after Neurosurgical Specialist assessment that excluded sinister structural or neurocompressive spinal instability with clinical assessment and MRI lumbar and sacro-iliac imaging. All study patients were referred to a single Neurosurgeon for back pain management due to a failure of primary care intervention. Symptoms were persistent for at least six months with all patients having attended their primary care physician and participated in at least one form of primary care or self initiated physical therapy. Delivery of the program was performed by NeuroHAB trained physical therapists.

Results

We defined NeuroHAB movement proficiency points of performance for what can be regarded as the functional “sport of life”:

1. Hip centric rotation
2. Neutral spine maintenance
3. Posterior kinetic chain activation
4. Unloaded knees (avoidance of anterior knee drive with a deactivated posterior kinetic chain)
5. Proficiency limited range of motion.

No patients commencing the program displayed proficiency in the above movement points of performance at commencement of the intervention when assessed with a simple standardized bending and sit to stand movement task.

The average ODI score improvement was 50 percent. Average ODI at the beginning of the program was 30 and improved to 15 after the program. Despite this data being derived without randomization or a control group, the substantial magnitude of the improvement in ODI which represents a gold standard measure of pain and disability is highly likely to be clinically and statistically significant.

Conclusions

Understanding this concept of movement proficiency or lack there of as a root cause for low back pain symptoms makes management simple, not complex as described by peer reviewed literature. ^17,18 If we up-skill back pain patients so that their central nervous system motor patterns express default movement consistent with NeuroHAB movement points of performance, substantial reduction in back pain can be observed in patients that could be considered biased toward a poor outcome by chronicity, having exhausted numerous other ineffective therapies and experienced negative psychological effects of chronic pain with the likely entrenchemnt of centralised pain pathophysiology.

Introduction

Existing research reveals deranged trunk muscle contraction in the presence of low back pain and even after pain has subsided electromyographic abnormalities in trunk control may remain. ^9,14 The corollary however has not been well investigated, that primarily corrupted motor patterns and subsequent movement dysfunction over time contributes to reduced functional capacity and the development of chronic low back pain. ²² Mechanisms by which movement dysfunction may contribute to chronic low back pain include both mechanical and central processes. The mechanical process involves the transformation of normally non-nociceptive degenerative elements of the lumbar spine into active nociceptors. ¹ We regard this transformation as “degeneritis”.

We also postulate a central process too that may shed light on chronic disabling low back pain in the presence of normal spinal integrity and absence of significant lumbar degenerative changes which is clearly not linked to the presence of back pain symptoms. The presence of persisting movement dysfunction itself may behave as “physiological nociceptor” manifesting with an obligatory cautionary central nervous system (CNS) signal of pain. Pain serves the purpose of cautioning the organism of real or potential threat. It is implicit that moving poorly is potentially injurious, therefore it is reasonable to consider that persisting movement dysfunction may behave as a “physiological” nociceptor in the absence of recognizable peripheral structural afferent nociceptive signaling from elements such as lumbar discs, facet joints and musculo-ligamentous soft tissues. The concept of a “physiological” nociceptor comprised of movement dysfunction is consistent with the IASP definition of pain which is “an unpleasant sensory and/or emotional experience associated with actual or potential tissue damage”. ²⁷ Targeting clearly defined movement dysfunction is a novel and potentially effective root cause based treatment strategy for chronic low back pain symptoms.

Methods

Movement proficiency or lack there of, in relation to low back pain has not previously been described. This study and treatment methodology required a non conjectural gold standard movement definition. This is referred to as NeuroHAB Movement Points of Performance or the NeuroHAB Screen:

1. Hip centric rotation
2. Neutral spine maintenance
3. Posterior kinetic chain activation
4. Unloaded knees (avoidance of anterior knee drive with a deactivated posterior kinetic chain)
5. Proficiency limited range of motion.

These criteria for proficient movement were chosen because they represented what we assessed as common characteristics of pain free natural spinal movement capable of relatively powerful functional capacity regardless of age, be they a naturally squatting toddler, an Olympic weightlifting champion and functional athlete or a pain free and independently functioning elder. Relative capacity or the ability to do the things in the “sport of life” is vastly different for all individuals however motor patterns and virtuosity in executing human movement according to these criteria should, in principle be maintained through out life if low back pain is to be avoided. Other research has shown that motor control of the spine is corrupted in the presence of chronic low back pain and we have observed in clinical practice this being manifested by gross deficiencies in the elements of movement characterized by the NeuroHAB screen. ^13,16,20

The NeuroHAB intervention is eight weeks in duration and comprises two, one hour sessions per week. Every session is solely movement focused with no manual, passive or recumbent therapy. The methodology is structured, step wise, progressive and reproducible. Patient’s movement skills increase steadily over the eight week program with virtuousity in obtaining default central nervous system motor patterns which manifest in the movement points of performance described by the NeuroHAB screen. Patients receive specific guidance and participate actively and repetitively in movement drills that promote the development of default motor patterns that express movement proficiency for activities of daily living and bending characterized by hip centric rotation with neutral spine awareness in the presence of an active posterior kinetic chain. These movement characteristics eliminate knee loading and anterior chain dominant movement such as kneeling.

Skill acquisition training for the “sport of life” can be considered in the same light as progressive skill acquisition for any other movement task or sport, such as a proficient golf swing, juggling or playing the violin. Improvement is observed in all skillful movement by focusing primarily on training the central nervous system, not the structural elements of the musculoskeletal system such as stretching, strengthening or releasing soft tissues which comprises much of current failing back pain rehabilitation methods.

Subjects

The only exclusion to participation was the presence of a specialist neurosurgeon deemed “movement obstructing barrier”. Logically in the presence of a “movement obstructing barrier” movement therapy cannot proceed or progress to effectively transfer the required skills required for proficient movement.

Movement obstructing barriers identified were:

1. Clinically and radiologically confirmed symptomatic neural compression
2. Overt mechanical instability
3. Gross structural compromise of core stabiliser and or lower limb strength.

A necessary requirement for inclusion was the absence of “movement obstructing barriers” and persistent low back pain for greater than 6 months. All patients were deemed to have failed the primary care offered to them by their local general practitioner which in all cases included regular pain medications and at least one but often multiple allied health physical therapy modalities and a multitude of pain interventions such as anaesthetic/corticosteroid injections, radiofrequency ablation, prolotherapy and acupuncture.

All patients participating were initially referred to a specialist neurosurgeon for assessment of intractable low back pain symptoms and for consideration of surgical intervention. No patient demonstrated competency in NeuroHAB defined movement proficiency at commencement of the intervention. If inclusion criteria were met patients were referred by the neurosurgeon for the NeuroHAB Functional Movement Therapy intervention.

Patients were considered to be biased to poor outcomes given the chronicity of symptoms and failure of first and second line treatment strategies including physical therapy, medications and invasive pain interventional injections and by the fact that symptoms had reached an intractable level that they were attending tertiary specialist neurosurgeon consideration of major surgical intervention.

Over a period of two years between 2015 and 2017, 142 patients participated in NeuroHAB Functional Movement Therapy and completed before NeuroHAB after NeuroHAB intervention ODI assessment questionnaires.

Results

ODI data was collected prospectively on 142 patients between 2015-2017 participating in the NeuroHAB Functional Movement Therapy intervention.

Patients were typical and representative of a specialist adult spinal neurosurgery practice in metropolitan Brisbane Queensland Australia. Age range was broad laying between 25 and 89 years old. 85 males and 57 females comprised the study group of 142 patients. Workers compensation back injury claims were not excluded and comprised 9 patients.

NeuroHAB movement points of performance for a standard bending and chair sit-stand task at commencement of the intervention were universally incompetent in at least one form in all patients. By completion of the eight weeks of NeuroHAB Movement Therapy the opposite was seen with a universal maintenance of all five NeuroHAB movement points of performance during re-assessment of the same standardized tasks.

The average presenting ODI was 31.7% and immediately at completion of the eight week intervention was 16.2%. This represents an average 15.5% absolute improvement and a 51.1% relative improvement in ODI scores.

Our examination of peer reviewed literature has not identified any methodology producing such marked clinical improvement in patient disability. This finding is quite remarkable in the face of a cohort of patients that, by our inclusion criteria, is biased to poor outcomes.

Discussion

Despite the fact that this remains a prospective observational study with short follow up, the magnitude and profound fifty percent improvement in ODI scores in our patient cohort who are biased toward failure suggests a highly clinically and statistically significant favorable intervention effect which cannot be ignored.

Low back pain is being recognized as a worldwide leading cause of disability with an associated mounting economic burden, particularly in industrialized nations and this is in spite of increasing technology and research dedicated to arresting the prevalence of this chronic disease. ^{6,10,12,18,26}

The increasing prevalence strongly points to a lack of efficacious treatment which is not, but should be referred to as, “Failed Rehabilitation Syndrome” similar to the commonly used term “Failed Back Pain Surgery Syndrome” and a dramatically increasing incidence or more than likely both processes occurring simultaneously leading to the observation of staggering incidence, persistence and recurrence of low back pain in our society. ^{18, 24}

This study and few before it suggest that the root cause of low back pain is a centrally driven movement dysfunction and not due to failings of spinal structural and associated soft tissue integrity. Which is often the mistaken conventional target of physical therapy and rehabilitation. ^{13,16,22, 29}

Intuitively movement dysfunction does not immediately cause pain but likely contributes to a reduction in functional capacity. An unfavorable mismatch between functional capacity and functional demand transforms the normal pain free spine with variable levels of degeneration into a painful spine, more appropriately termed “degeneritis”, when symptomatic. The unfavorable mismatch between capacity and demand is the trigger for pain, not the extent or substrate of degenerative change evident on radiological imaging. This scenario is encountered often in clinical practice where minimal degeneration is associated with high pain and disability and conversely significant degeneration can remain pain free. This is entirely consistent with the clinical observation well supported in peer reviewed literature that lumbar spinal imaging is the least relevant factor determining the presence of back pain symptoms. ¹⁹

This conceptualization of back pain symptoms being driven by movement dysfunction and reduced functional capacity is likely to explain the significant improvements we observed. The focus of our treatment intervention is to improve movement proficiency which is a mandatory and imperative requirement to then build functional capacity above the often minimal functional demands and requirements of chronic back pain patients.

The imperative to improving functional capacity is re-establishing movement proficiency. This concept can be described by the simple analogy of hiking with a stone in your shoe. The presence of the stone creates a dysfunctional gait to mitigate the pressure point of the stone on the foot. This movement dysfunction is maladaptive and over time results in central nervous system motor pattern corruption that entrenches the new maladaptive movement. With the further passage of time a reduction in functional capacity to complete the hike manifests primarily because of the manifesting movement dysfunction. This restriction of functional capacity reflected by progressive elimination of quality of life activities in back pain patients is clearly apparent. “Removing” the stone is equivalent to the NeuroHAB Functional Movement Therapy intervention. It allows our patients to regain our defined skills of movement proficiency and steadily re-build their required functional capacity. Movement proficiency can be regarded as the foundation stone or the concrete slab upon which functional capacity can be built.

Restoration of motor patterns which represents a central nervous system or “software” remedy as opposed to more conventional musculoskeletal “hardware” remedy is given little to no priority in peer reviewed literature due to a distinct lack of defined movement objectives for patients as they participate in their own “sport of life”. In fact there is wide conjecture amongst physical therapists regarding “neutral spine” and non neutral loading of the lumbar spine with the over riding nebulous message being simply to not fear movement, but omits imperative clear guidance for desirable proficient movement. ¹⁵ NeuroHAB Functional Movement Therapy is the only methodology identifiable in our literature review that clearly defines skillful movement points of performance goals for patients to acquire for the purpose of optimising defined movement proficiency and secondary improvement in back pain symptoms.

One may look to commonly performed motor control and exercise physiology, posture training and Physio-Pilates for guidance in this field however all of these movement and stability based approaches have been disappointing in the management of chronic low back pain. ^8,13,21,28 We postulate that this may be the factor that has resulted in a lull of research focusing on movement proficiency for low back pain management. However upon deeper interrogation of these methods, they can not be regarded as meeting strict criteria of effective central nervous system motor pattern rehabilitation and are overtly non functional in their implementation. Exercising, strengthening or learning to activate transversus Abdominus and/or multifidus may improve strength and motor control but does not translate to more proficient and skillful functional movement. Hence the observed disappointing outcomes obtained for treating back pain symptoms with these methodologies. ^{2,3,7,8,21,23,25,28}

From an evolutionary perspective humans have transformed from being quadrupeds to obligate bipeds. The kinematic demands of bipedal movement and bending has exposed the modern human to corruption of movement points of performance that would not be encountered in quadruped movement where NeuroHAB movement points of performance are observed to be maintained as defualt. Despite the vastly different spinal orientation and loads on the human spine compared to our quadruped ancestors, the human spinal form remains yet un-evolved for bipedal movement, if form is to follow function. This may represent an evolutionary clue to the global wide prevalence of back pain, especially in our modern less functionally demanding societies. Logically as bipeds if we re-establish key proficient kinematic principles which are described by NeuroHAB and also dictated by the form and function of our as yet un-evolved “bipedal” spine we may be able to mitigate low back pain symptoms.

Conclusion

Clearly defining movement points of performance for activities of daily living or the “sport of life”, is the first step in eliminating movement dysfunction. Acquiring movement proficiency, fundamental to optimizing functional capacity allows patients to exceed their individual functional demand. NeuroHAB Functional Movement Therapy is a unique and distinctive methodology that integrates all of these imperatives required to improve chronic low back pain symptoms. Implementation of NeuroHAB Functional Movement Therapy in 142 patients with at least 6 months of chronic low back pain who were biased toward poor outcomes based on failed primary and secondary care obtained a highly significant improvement in ODI scores after completion of eight weeks of structured progressive and reproducible NeuroHAB functional movement therapy. This clearly represents a paradigm shift in the right direction as it opens the window of opportunity for more research into functional movement therapy as the primary therapeutic target to eliminate the highly plausible disease of “Movement Dysfunction” that causes the symptoms of low back pain. This first ever published analysis of prospectively collected data directly reflecting restoration of NeuroHAB defined Movement Proficiency strongly supports this long overdue paradigm shift in chronic low back pain management.

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