Neuro-muscular control plays a big role in the management and prevention of chronic back and neck pains. It complements the rehabilitation therapy components that focuses on the joints, muscles and bones. With improved neuro-muscular control, the body is able to get the whole musculo-skeletal system working efficiently together.
What is Neuro-Muscular Control?
The key moving part in the body’s muscle skeletal system is the muscle. And this in turn is control by the nervous system The nervous system determine how much the muscle should contract, how much to relax, when to do so, and how quickly or slowly is should do so. Neuro-muscular control refers to the ability to do each of these things well.
Why is important?
To help us understand this, let’s think back to the time when you first learnt to ride a bicycle. The bike, like the human body, is made up of different parts. Some parts like the handle bar and seat should be firmly bolted to the bicycle frame. Other parts should be moving freely. In the human body, we have some joint that shouldn’t be tight and needs to move more freely and other joints that need to be tighter.
Other main part like the bike frame is like your skeletal structure. It basically holds everything else up. If the bike frame is weakened, eaten away by rust like bone osteoporosis, it might give way suddenly.
Now, when you ride the bike, you take the role of the muscle and nervous control system. Here it is too important that you are very strong in order to ride a bike. In fact, like most people you need some practice to learn to get your ‘balance’, perhaps starting with some training wheels at the back.
Learning how to balance is all about learning to pedal at the right pace, doing it smoothly, making small adjustments to your body’s center of gravity with slight shifts to the left and right as your pedal, small adjustments to the handle bars to compensate.
The key to note is that it is not about strength or endurance. If you have more strength and endurance, you will be able to ride faster and for longer periods of time. But without the proper ‘balance’ control, you won’t be able to ride at all no matter how strong you are.
Coming back to the human body, neuro-muscular control is the same; only now the bike is your body instead subtly moving your joints and supporting them. Like learning to ride a bike, it is easiest to just do it right slowly and keep practicing.
In this case study, we looked at Madam S, a lady in her late 60s. She had poor posture when walking and standing. Walking for more than 10 minutes on flat ground caused numbness and sensations of heat in both her legs. Over the past few years, her symptoms got progressively worse.
Initially, treatment involved a combination of different modalities and focused on the primary area of pain. Manual therapy was performed on the overactive muscles in her lower back to reduce the tension and to restore normal movement (not stiff) around her lower back. She was taught exercises such as pelvic tilts to allow conscious dissociation of the lower back portion of the spine from the chest portion of the spine and hips. Other stretching and flexibility exercises were also taught to maintain her mobility and achieve neutral spine position.
The second phase of the management involved teaching Madam S to develop an effective pattern of muscle activating to support her trunk or abdominal area.
Trunk stabilization involved re-education of the primary stabiliser muscles that help stabilise which involved lateral costal breathing and isolation of low effort pelvic floor, transverses abdominus and multifidus muscle contraction. This was done in supine position and separately to start, and was progressed to co contraction of all the stabilizing muscles in functional positions especially in standing and walking. Posture re-education and joint awareness of her lumbar spine, pelvis, knees were practiced with bio feed back such as in front of the mirror.
Once Mrs L was able to contract the pelvic floor, transversus abdominus and multifidus and perform lateral costal expansion, the 3rd and final phase of the management was carried out. This phase involved strengthening of the secondary stabilizers, such as the gluteal muscles, lat dorsi, and the external and internal obliques.
Status at 3 months
After 3 months of physiotherapy, which initial frequency was once a week for 5 weeks, then reducing to once every 2 weeks, Mrs L can now walk distances of 1km without pain. Her body awareness is now better and no longer stands in a swayed back posture.
This case illustrates the effectiveness of a multi approach system in solving this client’s back pain. In this instance, the role of manual therapy was to prepare the structures to adopt the new more neutral posture by increasing flexibility and “give” in the soft tissues and facet joints.
The improvement gained from the above cannot be sustained if the poor motor control present in Mrs L was not addressed. The role of transverses abdominus and multifidus is well documented and understood. However, recent literature has shown that the pelvic floor and the pattern of breathing are just as important in the stabilization system. A good analogy is to liken the trunk to a coke can. The top of the coke is the diaphragm, the bottom of the coke can is the pelvic floor and the side, transverses abdominus. The multifidus stabilizes the spine at the inter vertebral level. The idea of stabilization (apart from the multifidus) is to increase the intra abdominal pressure within the abdominal cavity. This is only possible if transverses can contract in a system where there is good tone in the pelvic floor and normal functioning of the diaphragm. In this case, Mrs L’s pelvic floor was weak and her breathing pattern was not conducive to transversus abdominus contraction. As her pelvic floor muscle was weak, it could not hold against the intra-abdominal pressure. Her breathing pattern caused a distention in her abdomen every time she inhaled which counteracted and opposed the activation of the transverses.
The lack of trunk stability probably led to the over activation of her back extensors which was recruited to compensate for the deficiency. This would have led to increased extension in the lumbar spine and hence her resultant posture.
Panjabi MM. The stabilizing system of the spine. Part 1. Function, dysfunction, adaptation, and enhancement. J Spinal Disorders 1992;5:383-389.