Questions Evidence for efficacy of Can training change motor

Effects of training 28/5/19

Paul Hodges CCRE SPINE UQ 2019 1

Evidence for efficacy of interventions:

Can we change motor control? Does it help if we do?

Paul Hodges

Questions

• Can training change motor behaviour in people with pain?

• Can training change motor system reorganisation?

• Can training change pain?

Outcomes of treatment• Improved structure & behaviour of deep trunk

muscles (Hides et al. 2001; Tsao et al. 2008)

• Reduced activity of superficial trunk muscles (Tsao, Druit & Hodges, 2010)

• Improved proprioception(Falla, Jull & Hodges, 2007)

• Improved spine posture(Falla, Jull & Hodges, 2007)

• Improved movement (Scholtes et al, 2010)

Weeks1 2 3 40

25

30

20

10

5

0

Cro

ss-s

ectio

nal a

rea

Exercise groupControl group

15

LSD = 3.92% (p<0.05)

Restoration of cross-sectional area - multifidus

Hides et al 1997 Spine

Marker of motor adaptation⇒ Changes in control of deep

musclesTrA

OI

OE

RA

ES

0 100-100

*

Time (ms)

Hodges & Richardson, 1996 Spine

OnsetTrA

Onsetdeltoid

TrA

OI

OE

RA

ES

Deltoid

50 ms TrAOIOE

RA

Specific Training

0

0.2

0.4

0.6

0.8

0

0.4

0.8

1.2

Onset Deltoid-100 100

Flexion

Extension

Nor

mal

ized

to p

re-tr

aini

ng p

eak

1.6

PostPre

Time (ms)

**

*

*

TrA



Can training change motor system reorganisation?

Pre

PreWalking exercise

00.2 0.4 0.6 0.8 1.0

Post

Post

Pro

p. P

eak

Skilled training

Can the organisation of the motor cortex be changed with exercise?

Tsao, Galea, Hodges (2010) Eur J Pain 14:832-9

Can training change pain? Systematic reviews• Saragiotto BT, Maher CG, Yamato TP, Costa LO,

Costa LC, Ostelo RW, Macedo LG. Motor Control Exercise for Nonspecific Low Back Pain. Spine. 41(16):1284-1295, 2016 .

• Ferreira PH, Ferreira ML, Maher CG, Herbert RD, and Refshauge K. Specific stabilisation exercise for spinal and pelvic pain: a systematic review. Aust J Physiother 52: 79-88, 2006.

• Macedo LG, Maher CG, Latimer J, and McAuleyJH. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther 89: 9-25, 2009.

Effect of treatment

Acute unilateral LBP ↓ LBP recurrence

Hides et al, 2001

Spondylolisthesis pain & disability

O’Sullivan et al 1997

Pregnancy-related pelvic pain

↓ pain & disabilityStuge et al 2003

Effect of treatmentMore effective for specific LBP phenotypes

Acute unilateral LBP

↓ LBP recurrence

Hides et al, 2001

Spondylolisthesis

pain & disability

O’Sullivan et al 1997

Pregnancy-related

pelvic pain

↓ pain & disability

Stuge et al 2003

Chronic non-specific LBP

↓ pain & disability & better

early vs. graded exercise

Ferreira et al, 2007


no additional benefit

Koumantakis et al, 2005


no additional benefit

Cairns et al, 2006



Response to motor control training depends on motor presentation

Baseline measures as a predictor of outcome

• TrA thickening (US imaging) during leg loading task - baseline

• N=34• Worse Baseline TrA thickening related to

greater change in pain• Interaction effect for pain -18.2 (1.4-35.0),

p= 0.035

Ferreira et al. (2010) Br J Sports Med

Baseline measures as a predictor of outcome

• TrA slide (US imaging) during voluntary activation of TrA – before & after treatment

• N=87• Pain - before & 1 year after treatment• Baseline TrA slide associated with likelihood for

improved pain level (OR 0.75, 0.57-0.98)

Unsgaard-Tøndel et al. (2011) Br J Sports Med

Response to motor control training depends on pain presentation

Response to motor control training depends on pain presentation

Time (months)0 2 4 8 10 12

2

4

6

8

6Time (months)

0 2 4 8 10 12

Func

tion

(0-1

0, u

nadj

uste

d)

2

4

6

8

6

Motor control

Graded exposure

Negative for LSIPositive for LSI

Macedo et al., (submitted)

Lumbar Spine Instability Questionnaire Cook et al. Man Ther. 2006;11(1):11-21

YES NOI feel like my back is going to “give way” or “give out” on me

I feel the need to frequently pop my back to reduce the pain

I have frequent times when my pain occurs throughout the dayI have a past history where my back catches or locks when I twist or bend my spineI have pain when I sit to stand or stand to sit I have a lot of pain when I sit up from lying down if I don’t raise up the right way

My pain is sometimes increased with quick, unexpected, or mild movementsI have difficulty sitting without a back support like a chair and feel better with a supportive backrestI cannot tolerate prolonged positions when I can’t move

It seems like my condition is getting worse over timeI have had this problem a long timeI sometimes get temporary relief with back brace or corsetI have many occasions when I get muscle spasmsI sometimes am fearful to move because of my painI have had a back injury from trauma in the past



Lumbar Spine Instability Questionnaire

• A measure of nociceptive pain?

Subgrouping: Evidence

0

5

10

15

20

25

30

35

Baseline 3 mo nth 12 m ont h

Oswestry Disability Index Q

M T-Ex

CB -CFT

0

2

4

6

8

Baseline 3 mo nth 12 m ont h

Pain intensity in last week

M T-Ex

CB -CFT

Vibe Fersum et al. 2013 Eur Spine J

• Subgroup – Non-specific chronic LBP (>3 months) – Provoked with postures, movement and activities

• Intervention– Classification-based cognitive functional therapy (n=62) or

manual therapy & exercise group (n=59)

* ** *

Who benefits from motor control training

• Motor control training is effective for specific subgroups (better for those with nociceptivefeatures with deficits in motor control), and when individualised to the patient

• Requires consideration of multiple domains to guide treatment– STEP 1: Is the patient appropriate for motor

control training (pain type)– STEP 2: What features of motor control require

modification

How can we make clinical decisions to guide optimal care

• Right treatment to right patient at righttime

• Hybrid method of treatment targeting

Pain mechanism based classification

• Identify mechanism of pain to guide treatment allocation

Pain neurobiology

• Not all pain is the same– Nociceptive/movement-related

• Assumed to be predominantly driven by activation of peripheral nociceptive fibres Scholz & Woolf, 2002

– Central/central sensitization• Amplification of neural signaling within the central

nervous system that elicits pain hypersensitivity – from cellular to widespread network Woolf 2011

– Neuropathic• Pain attributable to a lesion or dysfunction in the

peripheral or central nervous system Woolf, 2004



NOCICEPTIVE PAIN:Modification of tissue loading

• Detailed assessment of tissue loading: posture, movement, muscle activity & sensation

• Consider sub-grouping based on movement system

• Some consideration of psyshosocial

Nociceptive pain Central painNeuropathic painPain mechanism


Detailed assessment guided by pain mechanism group

Detailed assessment of tissue loading : posture, movement, muscle activity & sensationConsider sub-grouping based on movement system

General assessment of pain cognitions &

behaviours

MO

VEM

ENT

BASE

D

PSYCHO

-SOC

IAL BA

SED



Tailored physical therapy treatment

Individually tailored motor control training program to optimize tissue loading – may be guided by clinical reasoning +/- sub-grouping approachPhysical treatments to modify biomechanics (e.g. manual therapy)



behaviours

Pain education; reassurance; mild psychologically-informed treatment

MO

VEM

ENT

BASE

D

PSYCH

O-SO

CIA

L BASED

CENTRAL PAIN: Individually Tailored psychosocial intervention

• Detailed assessment of pain cognitions, behaviours, psychosocial features (e.g. depression), goals

• Some consideration of movement

Nociceptive pain Central painNeuropathic pain

Individually tailored psychologically-informed intervention• Fear conditioning• Pain coping skills• Acceptance• Etc.EducationBehavioural therapy (graded activity)Social intervention

Pain mechanism



Assessment of physical activity tolerance

Detailed assessment of pain cognitions,

behaviours, psychosocial features (e.g.

depression), goals

Physical activity/ exercise as within behavioural therapy program

MO

VEM

ENT

BASE

D

PSYCH

O-SO

CIA

L BASED



NEUROPATHIC PAIN: Combined loading and psychosocial intervention

• Assessment of relevance of psychosocial features

• Assess relevance of neural tissue loading; posture, movement, muscle activity neurodynamics,


Individually tailored neurodynamic/ motor control program to change nerve loading

Pain mechanism



Assess relevance of neural tissue loading; posture, movement, muscle activityneurodynamics,

Assessment of relevance of

psychosocial features


MO

VEM

ENT

BASE

D

PSYCH

O-SO

CIA

L BASED


Individually tailored neurodynamic/ motor control program to change nerve loading


Pain mechanism



Individually tailored motor control training program to optimize tissue loading – may be guided by clinical reasoning +/- sub-grouping approachPhysical treatments to modify biomechanics (e.g. manual therapy)


Assessment of physical activity tolerance

Assess relevance of neural tissue loading; posture, movement, muscle activityneurodynamics,


behaviours

Detailed assessment of pain cognitions,

behaviours, psychosocial features (e.g.

depression), goals

Assessment of relevance of

psychosocial features

Physical activity/ exercise as within behavioural therapy program


Pain education; reassurance; mild psychologically-informed treatment

MO

VEM

ENT

BASE

D

PSYCHO

-SOC

IAL BA

SED

Clinical studies: Outcome

• Motor control training reduces pain, disability and recurrence (Ferreira et al, 2006; Macedo et al, 2008)

• Better when targeted to specific groups and individualised

• Only exercise intervention better than placebo (Costa et al, 2010)

Physiological studies: Outcome• Motor control can be changed• Depends on what you do - better with

cognitive attention • Motor control improvements can be

maintained• Motor control improvement are

related to plasticity of the motor cortex (and most likely many other regions of nervous system)

Acknowledgements



A/Prof'Thomas'Graven1Nielsen,'Centre'for'Sensorimotor'Interac;on,'Aalborg,'Denmark'

'Prof'Alf'Thorstensson,'Karolinska'Ins;tutet,'

Stockholm,'Sweden''

A/Prof'Jacek'Cholewicki,'Yale'University,'New'Haven,'CT,'USA'

Dr'Mary'Massery''Chicago'USA'

Dr'Paul'Cordo,'Dr'Fay'Horak,'Oregon'Health'Sciences'University,'Portland,'OR,'USA''

''

Prof'Victor'Gurfinkel,'Russian'Ins;tute'of'Informa;on'Transmission'Problems,'Moscow,'Russia''

'

Prof'Sten'Holm'&'Dr'Allison'Kaigle,'Sahlgrenska'University'Hospital,'Göteborg,'Sweden'

''

Dr'Anne'Mannion,'Schultes'Klinik,'Zurich'Switzerland''Prof'Jaap'van'Dieen,'Vrije'University,'Amsterdam,'

Netherlands''

Dr'Paulo'Ferreira,'Dr'Manuela'Ferreira,'Universidade'Federal'de'Minas'Gerais,'Belo'HorizonteBrazil'

'

Prof.'Shinn1Zong'Lin,'Tzu'Chi'University,'Taiwan'''

Prof'Lieven'Dannees,'Gent'University,'Belgium''

'''

Prof'Simon'Brumagne'&'Prof'Sabine'Verschueren,'University'of'Leuven,'Belgium'

''

A/Prof'Francois'Hug,'Nantes'University,'France'''

Prof'Jayne'Garland,'Uni.'Bri;sh'Columbia''Prof'Laurent'Bouyer,'Uni'Laval,'Quebec,'Canada''Dr'Janine'Gray,'University'of'Cape'Town,'South'Africa'

Prof'Simon'Gandevia,'Dr'Jane'Butler,'NeuRA,'Sydney''Prof'Chris'Maher,'Prof'Chris'LiYle,'Sydney'University'Dr'Siobhan'Schabrun,'Prof'Lucy'Chipchase,'Uni'Western'Sydney'Prof'Lorimer'Moseley,'Uni'South'Australia'Prof'Michele'Sterling,'Griffith'Uni,'Gold'Coast''

Program'Grant'Team'Prof'Bill'Vicenzino''Prof'Kim'Bennell'Prof'David'Hunter''

Post1docs ' ''Dr'Natalie'Collins'Dr'Welber'Marinovic'Dr'Sauro'Salomoni ''Dr'Ryan'Stafford ' ''Dr'Ruth'Sapsford' ''A/Prof'Francois'Hug'Dr'Rachel'Park''

Research'staff'Wolbert'van'den'Hoorn'Markus'Kiel'Greg'James'Mandy'Nielsen'Glenn'Russell''''

Doctoral'students'(Past)''Andrew'Briggs'Angela'Chang''Andrew'Chapman'Andrew'Claus'Sallie'Cowan''Anna'Dawson''Janine'Gray'Allison'Greig''Leanne'Hall'Nick'Karayannis''Jo'Knox'Linda1Joy'Lee'David'Macdonald'Rebecca'Mellor''Nicola'Mok''Lorimer'Moseley'Rachel'Park''Peter'Poortvliet''Ruth'Sapsford'Ryan'Stafford'Steven'Saunders''Annina'Schmid'Michelle'Smith'Natalie'Spearing'Ryan'Stafford'Narelle'Stubbs''Henry'Tsao'Donna'Urquhart'Richard'Yang'

''

'

Doctoral'students'(Present)' ' ''Kim'Allison'Rafeef'Aljuraifani'Michael'Bergin'Catharina'Bexander'Edith'Elgueta1Cancino ''Alessio'Gallina ''Jan'Gildea'Luke'Heales'David'Klyne'Liam'Maclachlan'Laura'Morrison ''Camille'Shanahan'Viana'Vuvan'Peter'Window ''

UQ'Collaborators'Prof'Gwen'Jull''A/Prof'Sandy'Brauer ''Dr'Kylie'Tucker'Dr'Andrew'Claus'Dr'Michelle'Smith'

Twitter:@paulwhodges

Thank you

Questions Evidence for efficacy of Can training change motor

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