David Johnson (MBBS, FRACS – Neurosurgeon), Luke Armstrong (DipFit, NeuroHAB Movement Therapist)

Although the concept of movement dysfunction as a cause for musculoskeletal pain and specifically low back pain is referenced in the Literature. ^11,17,18 A sound, reproducible definition of movement proficiency in every day life activities, what we refer to as the “sport of life” is not well conceptualised by the the back pain therapeutic industry.  This skill is logically imperative for a healthy pain free musculo-skeletal system, to both prevent and rehabilitate the increasing prevalence of symptoms like chronic “non specific” low back pain.  A clear understanding and ability to transfer to patients the skill of proficient movement in the “sport of life” is critical, yet scarce amongst the medical and allied back pain therapeutic industry.  This commentary clarifies and defines movement proficiency points of performance for activities of daily living – “the sport of life” and provides insight into the clinically significant improvement that is possible in the most chronically effected back pain patients that ordinarily would be biased to poor outcomes after having exhausted years of conventional therapy with the exception of virtuously defined functional movement therapy.

The failings of the global back pain therapeutic industry to conceptualise movement dysfunction as the disease that causes chronic low back pain symptoms is reflected by the rising prevalence and economic burden of back pain symptoms upon industrialised nations. ⁸ As in every other disease process we can state with confidence that a lack of a clear definition of any disease will result in a futile therapy.

We propose that central nervous system (CNS) motor patterns are the “software” code for movement that is expressed by “hardware” joints, muscles, ligaments and tendons and that non specific low back pain symptoms are intimately linked to movement regardless of the inciting stimulus for the movement dysfunction, which for the most part is the micro-trauma of industrialised modern lifestyle that actively suppress movement proficiency. A definition of movement proficiency must be accepted first in order to implement a therapeutic model.

Another indication of the failure to recognise the concept of movement dysfunction is contemporary views reflected in O’Sullivan’s viewpoint article published in JOSPT entitled “Unravelling the Complexity of Low Back Pain”. ¹³ The title alludes to the very problem. Back pain symptoms are not complex if the root cause is clearly defined. Conversely without a definition of the root cause, effective management of symptoms will remain elusive, unpredictable, sub-optimal and appear complex. Sahrmann et al attempts to diagnose and treat Movement Impairment Syndromes based on “hardware” metrics like flexion, extension, rotation continuing to ignore “software” metrics of defining movement proficiency. ¹⁷

Movement clearly is a manifestation of both central nervous system “software” and musculoskeletal “hardware” out-puts. Sarhmann states in other research that “patients with low back pain have greater improvement in function and pain when performing corrected daily activities compared to adherence to exercise programmes”. ¹⁸ This finding is entirely consistent with the paradigm shift approach we put forth that the functional gains of proficient movement in back pain patients are far superior to those of hardware strength gains derived from exercise. Sadly the importance and definition of proficiency of the “daily activities” is once again overlooked in this paper likely due to the oversight that movement dysfunction is the disease that causes the symptoms. This makes their clinical observation logical not paradoxical, because futile exercise and enhanced core strength therapy does not mandate proficient movement which is the critical imperative.

One can observe practically and amongst the vast body of literature that an over-emphasis on the “hardware” elements of movement such as core strengthening, exercise therapy, mobility/range, and motor control fails to obtain a successful outcome for back pain symptoms. ^{2,4,6,7,10,14,19,20,21,22,23,29}

An omission of critical “software” central nervous system motor pattern restoration or nervous system rehabilitation is likely to be a primary reason for failing of physical therapy to manage back pain symptoms effectively.

The spine therapy industry is exceptionally good at addressing the “hardware”, strengthening muscles, mobilising soft tissue applying manual therapy and fusing motion segments all of which do not result in definitive resolution of symptoms when subjected to the rigor of scientific scrutiny for low back pain symptoms. ⁹ The same industry is without doubt, however very poor at correcting movement proficiency for the “sport of life”.

Regardless of the individual’s fitness, strength, agility or fused degenerate motion segments expressing poor kinematics on a second by second daily basis is the yet unrecognised element that requires reversal in order to prevent the development of back pain symptoms.

We define movement proficiency points of performance in the “sport of life” as:

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

These criteria for proficient movement are chosen because they represent the points of performance of a healthy spine, naturally maintaining powerful functional human movement regardless of age, be they a squatting toddler, an Olympic weightlifting champion or a pain free and independently functioning elder. ^1,3,5,15,16

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. ^12,13 If we up-skill back pain patients so that their central nervous system motor patterns express default movement consistent with the above movement points of performance all that is required is to allow time for the spontaneous healing power of human physiology to eliminate structural nociceptive and centralised pain afferents.

No strengthening, stretching or manual therapy regimen is required because these deficiencies are merely secondary to the movement dysfunction and over time also spontaneously improve once the foundation and skill of movement proficiency is re-acquired.

All would agree that strengthening a circus performer’s arms to juggle more ping pong balls is absurd. In order to effectively perform the, at first difficult movement skill of juggling is a “software” central nervous system up-skilling. The same principle is applied to our patients who remain poor at the movement in life or the “sport of life”. Hardware rehabilitation strategies will fail, however up-skilling central nervous system motor patterns likewise will be successful.

Outcomes to date of applying this principle of management is approximately a 50% reduction in prospectively collected Oswestry Disability Index Scores in patients suffering chronic low back pain greater than 6 months after conducting an 8 week nervous system rehabilitation programme encompassing the above defined movement points of performance.

It is imperative that future specific and directed research replicating our promising results which are due for systematic publication is conducted and accepted widely in order to make progress in the management of low back pain symptoms that remain a growing and leading cause of disability Worldwide.

Reference List:

• Bazrgari B, Shirazi-Adl A, Arjmand N. Analysis of Squat and Stoop dynamic Liftings: Muscle Forces and Internal Spinal Soads. Eur Spine J. 2006;16(5): 687-699.
• Clarke J, Van Tulder M, Blomberg S, De Vet H, Van der Heijden, Bronfort G, et al. Traction for Low Back Pain with or without Sciatica: An Updated Systematic Review within the Framework of the Cochrane Collaboration. J Spine. 2006; 31(15): 91-9.
• Cross Fit Journal. Retrieved from. 2002. library.crossfit.com.
• Furlan A, Imamura M, Dryden T, Irvin E, Yelland M, Del Mar C, et al. Massage for Low-Back Pain. Cochrane Database Syst Rev. 2008; (4).
• Glassman G. The Deadlift. Crossfit Journal. 2003; 12: 1-3.
• Hodges P, Cholewicki J, Van Dieen J. Opinions on the Links between Back Pain and Motor Control: The Disconnect between Clinical Practice and Research. New York, NY: Churchill Livingstone; 2013.
• Hayden JA, Van Tulder MW, Malmivaara A, Koes BW. Exercise Therapy for Treatment of Non-Specific Low Back Pain. Cochrane Database Syst Rev. 2005; (3).
• Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of Low Back Pain. Best Pract Res Clin Rheumatol. 2010; 24(6): 769-81.
• Johnson D, & Hanna J. Why We Fail, The Long-Term Outcome of Lumbar Fusion in the Swedish Lumbar Spine Study. Spine J. 2017; 17(5): 754.
• Macedo L, Maher C, Latimer J, McAuley J. Motor Control Exercise for Persistent, Nonspecific Low Back Pain: A Systematic Seview. Phys Ther. 2009; 89(1): 9-25.
• Miller, E., Sahrmann, S., & Avers, D. (2017). A Movement system impairment approach to evaluation and treatment of a person with lumbar radiculopathy: A case report. Physiotherapy Theory And Practice, 33(3), 245-253. http://dx.doi.org/10.1080/09593985.2017.1282997
• O’Sullivan, P. It’s Time for Change with the Management of Non-Specific Low Back Pain. Br J Sports Med. 2011; 46(4): 224-227.
• O’Sullivan P, Caneiro J, O’Keeffe M, O’Sullivan K. Unraveling the Complexity of Low Back Pain. J Orthop Sports Phys Ther. 2016; 46(11): 932–37.
• Osterhuis T, Costa LOP, Maher CG, De Vet HCW, Van Tulder MW, Ostelo RWJG. Rehabilitation after Lumbar Disc surgery. Cochrane Database Syst Rev. 2014; 14(3).
• Potvin JR, Norman RW, McGill SM. Reduction in Anterior Shear Forces on the L4 L5 Disc by the Lumbar Musculature. Clinical Biomechanics. 1991; 6(2): 88-96.
• Potvin J, McGILL S, Norman R. Trunk Muscle and Lumbar Ligament Contributions to Dynamic Lifts with Varying Degrees of Trunk Flexion. Spine. 1991; 16(9): 1099-1107.
• Sahrmann SA. The human movement system: our professional identity. Phys Ther. 2014;94:1034-1042. (2014). Physical Therapy, 94(12), 1828-1828. http://dx.doi.org/10.2522/ptj.20130319.cx
• Sahrmann, S., Azevedo, D., & Dillen, L. (2017). Diagnosis and treatment of movement system impairment syndromes. Brazilian Journal Of Physical Therapy, 21(6), 391-399. http://dx.doi.org/10.1016/j.bjpt.2017.08.001
• Saragiotto B, Maher C, Yamato T, Costa LO LC, Ostelo R, et al. Motor Control Exercises for Nonspecific Low Back Pain: A Chochrane Review. J Spine. 2016; (41).
• Thomson S. Failed Back Surgery Syndrome – Definition, Epidemiology and Demographics.Br J Pain. 2013; 7(1): 56-59.
• Van Middelkoop M, Rubinstein S, Kuijpers T, Verhagen A, Ostelo R, Koes B, et al. A Systematic Review on the Effectiveness of Physical and Rehabilitation Interventions for Chronic Non-Specific Low Back Pain. Eur Spine J. 2011; 20(1): 19-39.
• Yamato T, Maher C, Saragiotto B, Hancock M, Ostelo R, Cabral C, et al. Pilates for Low Back Pain: Complete Republication of a Cochrane Review. J Spine. 2016; (41).
• Walker B, French S, Grant W, Green S. A Cochrane Review of Combined Chiropractic Interventions for Low-Back Pain. J Spine. 2011; 36(3): 230-42.
• Williamson E, White L, Rushton A. A Survey of Post-Operative Management for Patients Following First Time Lumbar Discectomy. Eur SpineJ. 2006; 16(6): 795-802.