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Rehabilitation Through Precision: Restoring Function with Motor Control Exercises – A Case Study

Mathew Foreman¹, Junze Chen^1,2

¹Advance Healthcare Hoppers Crossing and Geelong

²RECOVER Injury Research Centre, CRE Better Health Outcomes for Compensable Injury, The University of Queensland

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Pain classification based on IASP:

Nociceptive pain

Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors.

Neuropathic pain

Pain caused by a lesion or disease of the somatosensory nervous system.

Nociplastic pain

Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain.

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Nociceptive pain (Shraim et al., 2022)

Subjective examination

Localised distribution of pain
Pain recovery or healing time predictable based on expected time of tissue recovery
Generally responsive to tissue-based treatments (eg manual therapy, massage, acupuncture, heat/cold, removal of tissue pathology, splints)
Pain provocation by specific postures and/or movements consistent with a nociceptive clinical pattern
Generally responsive to anti-inflammatory drugs
Generally not responsive to anti-convulsants or anti-depressants
Findings from imaging of body regions of potential relevance to the pain experience
Below cut-off (< 0) on Neuropathic Pain Questionnaire

Physical examination ± subjective examination

Signs of inflammation (redness, heat/warmth, tenderness, swelling) or a positive Clinical Inflammation Score (Ford et al 2018)
Proportional and direct relationship of pain response with physical examination
Pain provocation by testing of specific postures and/or movements consistent with a nociceptive clinical pattern including symptom modification
Pain provocation by special tests consistent with a nociceptive clinical pattern
No generalised hypersensitivity
Absence of autonomic symptoms and/or signs

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Nociplastic pain (Kosek et al., 2021)

1. All of the following criteria must be met

Chronic (> 3 months)
Regional (rather than localised and/or neuroanatomically plausible) in distribution
There is insufficient evidence that nociceptive pain (a) is present or (b) if present, is the dominant pain type
There is insufficient evidence that neuropathic pain (a) is present or (b) if present, is the dominant pain type

2. Subjective examination features of pain hypersensitivity in the region of pain with any one of the following:

Sensitivity to light touch or pin prick
Sensitivity to deep pressure
Sensitivity to movement
Sensitivity to heat or cold

3. Presence of comorbidities (of at least moderate severity) with any one of the following:

Increased sensitivity to sound and/or light and/or odours
Sleep disturbance with frequent nocturnal awakenings
Fatigue
Cognitive problems such as difficulty to focus attention, memory disturbances, etc

and/or a Central Sensitisation Index Score (Neblett et al 2013, Nijs et al 2015) of over 40

4. Pain hypersensitivity during the physical examination distal to and/or in the region of pain with any one of the following:

Dynamic mechanical allodynia to light touch
Static mechanical sensitivity to deep pressure
Heat or cold sensitivity
Painful after-sensations reported following the assessment of any of the above

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Criteria for anterior trunk muscles	Score
Quality of transversus abdominis activation
Unable to contract TrA (Palpation – no increase in muscle tension; Observation – no inward motion of lower abdominal wall; Ultrasound imaging – no thickening or lateral slide)	☐ 0
Able to perform contraction of TrA that is just perceptible (Palpation – very slight increase in muscle tension; Observation – very subtle inward motion of lower abdominal wall; Ultrasound imaging – slight thickening or lateral slide)	☐ 1
Able to contraction TrA but with poor quality – rapid, jerky, tentative	☐ 2
Able to perform slow, smooth and confident contraction of TrA (Palpation - gentle increase in muscle tension; Observation - inward motion of the lower abdominal wall; Ultrasound imaging – smooth gentle thickening or lateral of the muscle)	☐ 3
Substitution by superficial trunk muscles
Contraction of the superficial trunk muscles at rest in a supported position and inability to relax (Palpation, observation, electromyography)	☐ 0
Moderate/high level contraction of superficial muscles during attempted contraction of TrA (Palpation, observation, ultrasound imaging, electromyography)	☐ 1
Subtle contraction of superficial muscles during attempted contraction of TrA (Palpation, observation, ultrasound imaging, electromyography)	☐ 2
Contraction of TrA with no/minimal activation of superficial muscles (identified using observation, palpation, +/- ultrasound imaging, electromyography)	☐ 3
Symmetry of contraction
Unilateral/no contraction – Unable to contract TrA with high quality* or on one side only	☐ 0
Bilateral asymmetrical - Able to contract TrA on both sides, but with asymmetrical quality (high quality* on one side only)	☐ 1
Bilateral symmetrical - Able to contract TrA with high quality* on both sides	☐ 2
Breathing pattern
Unable to maintain high quality* contraction during breathing or only hold with major change in breathing pattern (shallow breaths or dominant upper chest breathing pattern)	☐ 0
Able to maintain high quality* contraction during breathing	☐ 1
Holding/endurance
Unable to maintain high quality* contraction for 10 s	☐ 0
Able to maintain high quality* contraction for 10 s or more	☐ 1
TOTAL SCORE	/10
Major substitution with (muscle): Symptom response to correction:

Hodges and Ford 2024

*High quality contraction of TrA

- Able to perform slow, smooth contraction of TrA (Palpation - gentle increase in muscle tension; Observation - inward motion of the lower abdominal wall, Ultrasound imaging – smooth gentle thickening or lateral of the muscle) with no/minimal activation of superficial muscles (identified using palpation, observation, +/- ultrasound imaging, electromyography or superficial muscle)

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Hodges and Ford 2024

*High quality contraction of MF - Able to perform slow, smooth contraction of MF (Palpation - gentle increase in muscle tension; Ultrasound imaging – smooth gentle thickening and movement predominantly of deeper fascicles in MF) with no/minimal activation of superficial muscles (identified using palpation, observation, +/- ultrasound imaging, electromyography of superficial muscles)

Criteria for posterior trunk muscles	Score
Quality of lumbar multifidus activation
Unable to contract MF (Palpation – no increase in muscle tension; Ultrasound imaging – no thickening of MF or movement of MF muscle fascicles)	☐ 0
Able to perform contraction of MF that is just perceptible (Palpation – very slight increase in muscle tension; Ultrasound imaging – slight thickening or movement of muscle fascicles)	☐ 1
Able to contraction MF but with poor quality or only at some levels – rapid, jerky, tentative	☐ 2
Able to perform slow, smooth and confident contraction of MF (Palpation – gentle smooth increase in muscle tension; Ultrasound imaging – smooth gentle thickening of MF and movement predominantly of deeper fascicles in MF)	☐ 3
Substitution by superficial trunk muscles
Contraction of the superficial trunk muscles at rest in a supported position and inability to relax (Palpation, observation, electromyography)	☐ 0
Moderate/high level contraction of superficial muscles during attempted contraction of MF (Palpation, observation, ultrasound imaging, electromyography)	☐ 1
Subtle contraction of superficial muscles during attempted contraction of MF (Palpation, observation, ultrasound imaging, electromyography)	☐ 2
Contraction of MF with no/minimal activation of superficial muscles (identified using observation, palpation, +/- ultrasound imaging, electromyography)	☐ 3
Symmetry of contraction
Unilateral/no contraction – Unable to contract MF with high quality* or on one side only	☐ 0
Bilateral asymmetrical - Able to contract MF on both sides, but with asymmetrical quality (high quality* on one side only)	☐ 1
Bilateral symmetrical - Able to contract MF with high quality* on both sides	☐ 2
Breathing pattern
Unable to maintain high quality* contraction during breathing or only hold with major change in breathing pattern (shallow breaths or dominant upper chest breathing pattern)	☐ 0
Able to maintain high quality* contraction during breathing	☐ 1
Holding/endurance
Unable to maintain high quality* contraction for 10 s	☐ 0
Able to maintain high quality* contraction for 10 s or more	☐ 1
TOTAL SCORE	/10
Atrophy present at (level(s)): Poor activation at (level(s)): Major substitution with (muscle): Symptom response to correction:

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Motor control practice for intervertebral disc related disorders (Ford et al., 2012)

ˆMVC = maximal voluntary contraction

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Motor control practice - How can we make clinical decisions to guide optimal care

Right treatment to right patient at right time.

Motor control training is effective for specific subgroups (i.e., better for those with nociceptive features with deficits in motor control), and when individualised to the patient

Hybrid method of treatment targeting (e.g., for those with nociplastic features) psychological factors including fear-avoidance, pain coping skill, acceptance, depression/anxiety/stress, or PTSD should be assessed. Less focus on motor control so to avoid patient becoming bio-focused). Multidisciplinary pain management program is indicated if this is the case.

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Thank you !