Motor Control Approach For Back Pain Uilizing Real-Time Ultasound Imaging

Motor Control Exercises with Real-Time Ultrasound Imaging:
Transversus Abdominis, Lumbar Multifidus, and Pelvic Floor Muscles

During the last decade, researchers in Australia have made breakthrough discoveries in the treatment of back pain. Through the use of real-time ultrasound imaging technology they identified problems with the deep "stabilizing" muscles of the lumbar spine and pelvis (lumbar multifidus, transversus abdominis) in patients who had experienced back pain. Subsequently, they have developed the motor control approach to examine, diagnose, and treat these specific muscles with the help of ultrasonography.

Evidence shows that the function (or dysfunction) of these local muscles determines whether a person experiences long-term pain relief or a return of symptoms (recurrence of back pain). The positive or negative response depends on whether the deep "stabilizing" muscles are properly rehabilitated or not.

The issue of recurrence is important because a return of symptoms may lead to a chronic, disabling condition. Recent studies show that back pain does return in most people (80% recurrence) within a year after experiencing symptoms for the first time.

Current research would suggest that it does not matter who you see for treatment (family practice physicians, chiropractors, acupuncturists, or physical therapists). If you do not rehabilitate the deep "stabilizing" muscles, then the recurrence rates are about the same as those who receive no treatment at all (80%).

How is the motor control approach for back pain different than other physical therapy techniques?
No other treatment technique has targeted the deep "stabilizing" muscles (lumbar multifidus, transversus abdominis). In fact, most physical therapists and medical doctors in the United States do not know about the proper function of these muscles or that they always become dysfunctional after experiencing back pain.

This is not to say that other physical therapy techniques are worthless, but just that they do not target the deep "stabilizing" muscles, therefore these muscles will not be rehabilitated properly and recurrence of back pain is likely to occur (80% of the time).

Are other treatment techniques necessary?
Other physical therapy techniques that help to relax superficial "strength" muscles are also important because this is a prerequisite to initial training of the deep "stabilizing" muscles. Relaxing the superficial "strength" muscles may also provide symptom relief (although duration of pain-relief may be brief).

There are also techniques that address the connective tissue component of pain. Connective tissue can be laid down in an irregular fashion during the repair process after injury or repetitive strain. This can restrict joint motion and may constrict & irritate the nervous system causing the superficial "strength" muscles to go into spasm.

Muscle spasm is inherently painful because of restricted blood-oxygen supply to the muscle and build-up of acids. Muscle spasm also restricts joint motion and may compress portions of the nervous system producing additional pain.

Therefore, a vicious cycle may result if connective tissue irregularities and muscle hypertonicity and spasm are not addressed.

But, even after treating these two components of the problem, if we neglect to rehabilitate the deep "stabilizing" muscles, recurrence of low back pain is still likely to occur (in 80% of individuals). This is why the discovery of the function and dysfunction of these local muscles is so important to the rehabilitation process. Because...

Motor control is the key to long-term pain control!

During the last ten years, expert physical therapists have significantly altered the way they are prescribing exercise for lumbopelvic dysfunction thanks to research that initiated at the University Queensland in Australia. Before their research, we relied mostly on anecdotal evidence and it is safe to say that nobody had the answer to effective treatment of lower back pain. None of the treatments by physical therapists, medical doctors, or chiropractors showed significant long-term effectiveness in the fight against recurrent lower back pain. There was something missing and when it was discovered it was like "turning on a light," both figuratively and literally.

From Therapeutic Exercise For Lumbopelvic Stabilization, 2nd Edition by Carolyn Richardson, Paul Hodges, and Julie Hides.

Why Real-Time Ultrasonography is important.
The realization of the importance of the deep muscle corset concept for the support of the lumbopelvic region has come through the clinical use of real-time ultrasound... This imaging technique has allowed the deep musculo-fascial system to be viewed in its normal and dysfunctional state. One important feature of using RTU to image the corset is that it allows observation of tension and sliding of fascias (which cannot be palpated or detected with the use of fine-wire EMG).

The most dramatic development in conservative care for the spine within the practice of physical therapy has been the use of real-time ultrasound imaging to diagnose and treat Lumbo-Pelvic dysfunction. The sound waves of the ultrasound imaging machine penetrate through the tissues and into the deep muscles. The "echo" (of the sound waves) that returns is picked up by the transducer and converted into "light" when displayed on the monitor. It is sometimes easier to think of ultrasound imaging as shining a bright, focused beam of light into your body so that we can see what is going on with the muscles and other soft tissues all the way down to the bone.

From Diane Lee's textbook: "The Pelvic Girdle" 3rd edition

The Pelvic Girdle third edition by Diane Lee

"New concepts of how joints are stabilized and how load is transferred through the body highlight the importance of proprioception (body awareness), automatic muscle activity, and motor control for regaining optimal movement after injury. It is clear from this body of evidence that successful rehabilitation of back pain and dysfunction requires exercises that differ from those used for conditioning and training the healthy, non-painful, non-injured population."

Transversus Abdominis, Multifidus, and Pelvic Floor Muscles
Maybe you have heard of two or three of the more famous deep "stabilizing" muscles we look at with real-time ultrasound imaging (RTUI). One is called Transversus Abdominis. It is the deepest lateral abdominal muscle and lies beneath the internal and external obliques.

This muscle is often referred to as the body's natural "corset," like the one that Scarlet O'Hara wore in the Classic Movie: Gone With The Wind.

Another important deep "stabilizing" muscle is Lumbar Multifidus which is located on either side of your backbone. We also examine the pelvic floor muscles with RTUI.

Is there scientific evidence that this approach works?
The latest research indicates that deep �stabilizing� muscles of the lumbar spine and pelvis become dysfunctional after you experience back pain and that rehabilitating these muscles with specific exercise is the key to long-lasting pain relief.

The only successful way to examine, diagnose and retrain these muscles is with this revolutionary approach that uses real-time ultrasound imaging.

Real-Time Ultrasound Imaging of Deep Muscles
We use RTUI to examine, diagnose and treat the deep "stabilizing" muscles of the lumbopelvic region (the lower back). This is the same technology that lets us "see" a growing baby in a mother's womb.

We use RTUI to show you whether these muscles are working properly. Then, we will use the same technology to retrain proper function through visual biofeedback during specific exercise.

RTUI allows us to assess the "action" of deep muscles that stabilize the individual joints of the lumbar spine and pelvis (a.k.a. segmental stability). This muscle action cannot be palpated (felt with the examiner's fingers) even by the most expert of physical therapists. In fact, the only other way to assess the muscle action of the deep muscles is by MRI, but this is not practical in a clinical setting and is too expensive for repeated treatment.

(Note: Because we know that both prospective patients and other physical therapists may be reading this website, I will include some of the more technical issues in the "Clinicians Corner.")

Clinician's Corner
Until recently, fine-wire EMG was thought of as the "gold standard" for assessing transversus abdominis. But EMG cannot determine whether the contraction is eccentric or concentric.

RTUI is used to examine and diagnose the deep muscles that are not doing their part to stabilize the lower back and pelvis. We also use RTUI to help you learn how to use these muscles properly again through visual biofeedback.

Scientific Research on Deep "Stabilizing" Muscles
Scientific research performed on the deep "stabilizing" muscles utilizing RTUI has revolutionized the way that experts are treating back pain. Research has shown us what their normal function is and we also know that pain in the region (which is actually experienced in the brain) causes these muscles to become dysfunctional.

The muscle "dysfunction" is a problem with motor control (the brain's strategy for stabilizing the joints of the lower back), it is not a strength issue. So, we use a motor control approach for treatment of lower back pain. What this means is that we will help you learn to connect your brain to the problematic muscle through specific exercise training. It also means that trying to strengthen the deep "stabilizing" muscle during rehabilitation is not an effective treatment (in fact it only reinforces the dysfunction).

Precision is Necessary to Reprogram the Brain for Optimal Stabilization
For proper brain reprogramming, you must target the right muscle for the right task during rehabilitation.

This is nothing new... just look at the different exercise programs used to train athletes of various sporting events. Can you imagine using the same training program that a power-lifter uses, when your sporting event is long distance running?

Yet, we would argue that physical therapists are prescribing exercises for back pain patients that are even more inappropriate.

What the health professions are doing as a whole is not working. The pain returns within a year in 80 percent of the patients treated for low back pain (this is what we call recurrence of back pain).

Conventional & Alternative Treatments have No Long-Term Benefit
The research over the past decade has been telling us that no matter what treatment you receive by a Family Physician (usually medication and a pamphlet on "How to treat low back pain at home"), a Chiropractor (manipulation), Acupuncturist, or conventional physical therapy (including general exercise program, thermal ultrasound, electric stimulation, McKenzie program, massage), none of these reduce pain recurrence rates. Or, in other words, these treatments do not provide long-term pain relief.

Treatment Approach with Long-Term Benefits
A three-year study showed that the group of patients who participated in a conventional physical therapy program with generalized exercises was 12.4 times more likely to have pain symptoms return, then the other study group who participated in the motor control approach program with RTUI.

In the motor control approach program with RTUI, the specific dysfunctional muscles are identified via RTUI then these muscles are reprogrammed for optimal function. From this and many other studies we know that reprogramming the deep "stabilizing" muscles for optimal function is the key to long-term pain relief.

What Medical Diagnoses may be Successfully Treated with the Motor Control Approach Utilizing RTUI?

Lumbago
Non-specific back pain
Mechanical low back pain
Chronic low back pain
Acute low back pain
SI joint pain
Chronic groin strain
Incontinence
HNP
Bulging disc
Degenerative disc
Facet joint syndrome
Spondylolisthesis
Spondylolysis
Spondylosis
Osteoarthritis
Spinal instability
Muscle spasm
Sciatica
Piriformis syndrome
Lumbar radiculopathy
Lumbar stenosis
Lumbar instability
Post-surgical laminectomy, diskectomy, fusion
Pre-surgery candidates
etc...

Once again, Welcome!

Howard Knudsen, PT
Howard A. Knudsen, PT
Independent Doctor of Physical Therapy
Advance expertise in use of real-time ultrasound imaging for motor control assessment and exercise prescription. Certified provider of ASTYM^TM treatment.

Our clinic is located at:
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3585 North University Avenue, Suite 100
Provo, UT 84604
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P. S. Do you have a question about some aspect of your back or neck pain? Contact me online, and I will get back to you promptly.

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Thanks!

Last update:
Monday August 21, 2006